Renal/Genitourinary Flashcards
Functions of the kidney
AWETBED
Acid-base homeostasis
Water balance
Electrolyte balance
Toxin/waste product removal
Blood pressure control
Ertyhropoietin
D (vitamin D activation)
Define Acute Kidney Injury
A sudden decline in kidney function leading to a rise in serum creatinine and fall in urine output.
What can renal dysfunction cause
Dysregulation of
- Fluid balance
- Acid-base homeostasis
- Electrolyte imbalance
Drugs to stop in acute kidney injury
DAAMN
D - Diuretics
A - ACEi/ARB
A - Aminoglycosides
M - Metformin
N - NSAIDs
ACEi/ARB protective in Chronic
6 pre renal causes of AKI
Hypoperfusion
- Hypovolaemia (bleeding, reduced cardiac output (CHF), cardiogenic shock)
- Liver failure (hypoalbuminaemia)
- Renal artery blockage/stenosis
- ACEi & NSAID
- Sepsis causing systemic vasodilation
- Dehydration
4 intrarenal causes of AKI
Intrinsic disease of kidney
- Acute tubular necrosis
- Acute interstitial nephritis (these 2 can be drug induced)
- Glomerulonephritis
- Small vessel vasculitis
4 post renal causes of AKI
Obstruction to urinary outflow, causing back pressure into kidney. (Obstructive uropathy)
- BPH
- Urolithiasis
- Cervical and prostate cancer
- Bladder neck stricture
Risk factors of AKI
- Age >65
- Heart failure
- Diabetes
- Poor fluid intake
- Hypovolaemia
- Nephrotoxic meds (NSAID, ACEi)
- Contrast medium usage in imaging
- Prostate cancer
- BPH
- Sepsis
- Liver disease
Electrolyte consequences of AKI
Hyperkalaemia and azotaemia (increased blood creatinine and urea)
Metabolic acidosis
Symptoms of pre renal AKI
Hypotension
Reduced capillary refill
Dry mucus membranes
Reduced skin turgor
Cool extremities
Intra renal AKI symptoms
Infection/ signs of underlying disease (vasculitis, glomerulonephritis etc)
Post renal AKI symptoms
Loin to groin pain
Haematuria
Palpable bladder/prostate
Prostatic urinary issues (dysuria, terminal dribbling, hesitancy)
Causes of Acute tubular necrosis
Ischaemia - Pre renal disease
Nephrotoxicity - (aminoglycosides, chemotherapy), contrast in CT, myoglobin, multiple myeloma
Pathophysiology of acute tubular necrosis
Nephrotoxins (aminoglycosides, NSAIDs, uric acid) can kill epithelial cells. When cells die, they block tubules increasing pressure. Less filtration occurs, causing azotaemia, hyperkalaemia and metabolic acidosis.
Pathophysiology of prerenal AKI
Less blood into kidney usually due to hypovolaemia causes activation of RAAS system
Na+ and urea reabsorbed, leading to oliguria
Causes less urine output which is more concentrated
Diagnostic criteria for AKI (stage 1)
- Rise in creatinine > 26μmol/L within 48 hours
- Rise in creatinine >1.5 x baseline (i.e. before the AKI) within 7 days.
- Urine output <0.5ml/kg/hour for >6 consecutive days.
Investigations in AKI
Check for hypo/hypervolaemia and urine output
FBC, U&E, ABG, Creatinine Kinase, Urine output should all be checked.
Urinalysis
Imaging
- Ultrasound - urinary tract to look for obstruction
- CXR - Signs of volume overload (cardiomegaly, pulmonary oedema)
- ECG - Hyperkalaemic changes
- CTKUB check obstruction
What urinalysis is conducted in AKI
Urine osmolality and electrolytes checked
Dipsticks - Leucocytes and nitrites = infection
Protein/ blood = acute nephritis
Glucose suggests diabetes
Treatment of AKI
Prerenal: IV fluids and treatment of sepsis
Intrarenal: Stop nephrotoxic drugs, treatment specific to condition
Post renal: Catheter in BPH
Treatment of AKI complications
Hyperkalaemia
- Calcium gluconate (protect myocardium)
- Insulin/dextrose (drive K+ into cells)
- Stop K+ sparing medication
Acidosis
- Sodium bicarbonate
Pulmonary oedema/hypervolaemia
- Diuretics
Complications of AKI
- Hyperkalaemia
- Fluid overload from treatment
- Metabolic acidosis
- Uraemia (encephalopathy/pericarditis)
- CKD
Classification systems in AKI
KDIGO (Kidney Disease: Improving Global Outcomes)
RIFLE (Risk Injury Failure Loss Endstage renal disease)
Staging of AKI
KDIGO criteria
Stage 1
- Creatinine >26 or 1.5-1.9x baseline in <48hr
- Urine output <0.5ml/kg/hr for 6-12 hours
Stage 2
- >2-2.9x baseline creatinine
- Urine output <0.5ml/kg/hr for >12 hours
Stage 3
>353 or 3x reference creatinine
<0.3ml/kg/hr for >24 hours or anuria for >12
Define CKD
Progressive deterioration in renal function over at least 3 months characterised by eGFR of <60ml/min/1.73m²
What 2 tests are considered in CKD classification
eGFR and albumin:creatinine ratio
How is eGFR used to stage CKD
Stage 1 - >90 (normal)
Stage 2 - 60-89 (mild reduction, only CKD if symptoms)
Stage 3a - 45-59 (mild-moderate reduction)
Stage 3b - 30-44 (moderate-severe reduction)
Stage 4 - 15-29 (severe reduction)
Stage 5 <15 (End stage kidney failure)
How is albumin:creatinine ratio used to stage CKD
Checks proteinuria to give A score
A1 - <3mg/mmol
A2 - 3-30mg/mmol
A3 - >30mg/mmol
What can be used as evidence of renal damage?
- Albuminuria (ACR>3)
- Electrolyte abnormalities
- Histological abnormalities
- Structural abnormalities on imaging
- Kidney transplant history
- Urine sediment abnormalities
At what eGFR is metformin contraindicated
<30ml/min/1.73² (stage 3b)
Causes of CKD
Most common: Diabetes and HTN
Nephrotoxic drugs
Glomerulonephritis
Systemic disease e.g. rheumatoid arthritis/SLE
How does CKD lead to its complications
low eGFR = azotaemia (which can cause encephalopathy and pericarditis)
Urea affects platelet function (bleeding)
Uremic frost (urea crystals in skin)
Kidneys normally activate vit D. No activation = hypocalcaemia = PTH secretion = bone resorption (renal osteodystrophy)
Low fluid to kidney = RAAS activation = HTN
HTN causing increased intraglomerular pressure - causing shearing and loss of selective permeability (protein/haematuria)
Kidneys produce less EPO = Anaemia
Signs/symptoms of CKD
Asymptomatic at first
Uraemic frost (tiny yellow white urea crystals on skin)
Uraemia swallow (pale/brown colour on skin)
Pallor
Fatigue
Lethargy
Frothy urine
Swollen ankles/oedema
Increased bleeding
What does anaemia, with low calcium and low phosphate imply
CKD
Investigations in CKD
Urine dipstick
- Haematuria, glycosuria
eGFR and urine albumin:creatinine ratio
U&E
FBC
- Normocytic normochromic anaemia
Bone profile/PTH
- Ca2+ low, phosphate high, PTH high, ALP high
Renal ultrasound
Bilateral kidney atrophy (small kidneys)
Complications of CKD
Anaemia (EPO reduced)
Osteodystrophy (decreased vit D activation)
Neuropathy/encephalopathy
Pericarditis
Treatment of CKD
No cure except transplant, can only treat symptoms
Anaemia - EPO + Iron
Osteodystrophy - Vit D supplementation
CVD - ACEi + statins
Oedema - Diuretics
(ACEi help in CKD but harm in AKI)
What is RRT and what are its indications
Renal replacement therapy - Persistent severe complications (electrolyte, oedema, uraemia) or Stage 5 CKD
AEIOU
Acidosis > 7.2 - Acidosis not helped by sodium bicarbonate
Electrolytes K+>7mmol/L
Intoxication - Stage 5 CKD
Oedema
Uraemic pathology - Encephalopathy, pericarditis etc
What are the types of RRT
Haemodialysis (most common)
- Blood taken from artery, filtered and returned into vein at AV fistula.
- 3x4 hours a week
- Complications: hypotension, nausea, chest pain, infected catheter (sepsis)
Peritoneal dialysis
- Peritoneal catheterisation, exchange of solutes across peritoneal membrane
- Done at home
- Complications: Peritonitis, abdominal wall hernia
Causes of CKD-mineral bone disease
Reduced 1-alpha hydroxylase activity (reduced vit D activation)
Reduced renal excretion of phosphate (phosphate stimulates bone resorption)
Treatment of CKD mineral bone disease
Reduced dietary phosphate (fish, meat, poultry)
Vit D replacement (calcitriol is already 1-alpha-hydroxylated)
Phosphate binders
Bisphosphonates
BP Targets in CKD
140/90 or 130/80 if coexisting diabetes
ACEi used (reduce filtration pressure, less proteinuria)
Define renal colic
AKA Nephrolithiasis
Formation of renal stones in urinary system
Pathophysiology of Nephrolithiasis
When solvent (water) too low, or solute too high, solutes can precipitate and crystallise, forming a nidus. More solutes precipitate around this, forming kidney stone.
Mg and Citrate inhibit crystal growth
What are the types of kidney stone, how do they form and how do they show?
Calcium oxalate (most common)
- Black/dark brown, radiopaque on X ray
- Form in acidic urine
Calcium phosphate stones
- Dirty white, Radiopaque
- Form in alkaline urine
Struvite stones (magnesium, ammonium. phosphate)
- Dirty white, radiopaque
- AKA infection stones, form during UTI (UTI organisms hydrolyse urea into CO2 and ammonia)
Uric acid stones
- Red-brown, radiolucent (transparent to X ray)
- High purine diet, dehydration, acidic urine
Cystine stones
- Yellow/light pink, radiopaque
- Cystinuria, autosomal recessive condition causing decreased cystine absorption
Renal stone appears dirty white and radiopaque, which 2 could it be?
Calcium phosphate
Struvite
(struvite forms during UTI)
Risk factors for renal stone development (7)
Dehydration
Low urine output
Hypercalcaemia, Hypercalciuria Hyperparathyroid
Previous kidney stones
Foods high in oxalate, phosphate or calcium (spinach, tea, rhubarb, chocolate)
Gout
Renal tubular acidosis
Signs/symptoms of nephrolithiasis
Severe, colicky loin to groin pain
- Lasts minutes to hours and fluctuates in severity
- Caused by peristalsis against stone (dilation, stretching and spasm due to obstruction of ureter)
Flank/renal-angle tenderness
Fever
Nausea/vomiting
Haematuria
(Hypotension and tachycardia if sepsis)
2 most common renal stone sites
- Ureteropelvic junction
- Renal pelvis (staghorn calculi form here)
Investigations in nephrolithiasis
Urine dipstick - haematuria (+ leucocytes and nitrites if infection)
Abdominal X ray - calcium based stones
USS KUB - Pregnant or under 16, only radiopaque
NCCT-KUB (Non Contrast CT of Kidney, Ureter, Bladder) - Stones seen in renal collecting system or ureter
Management of Nephrolithiasis
Hydration
IV diclofenac for renal colic
Antibiotics for UTI
Surgery if stones too big
- Extracorporeal shockwave lithotripsy (CI in pregnant)
- Percutaneous Nephrolithotomy (PCNL)
Kidney stone recurrence prevention
Citrus e.g. lemon juice (citric acid binds to urinary calcium)
Avoid cola drinks
Potassium citrate
Cystine binder if cystine stone
Thiazide diuretics (increase Ca2+ excretion)
What are the upper and lower UTIs
Upper - Pyelonephritis (renal parenchyma and renal pelvis)
Lower
- Urethritis (Urethral inflammation usually due to STI)
- Cystitis (Infection of bladder)
- Prostatitis (acute/chronic infection of prostate)
- Epididymis-Orchitis (epididymis, extends to testes, usually 2° to urethritis or cystitis)
How do you know if a UTI is complicated? (7)
If it affects:
a man
a pregnant lady
a baby
the immunocompromised
it is recurrent
people with abnormal urinary tracts (e.g. stones)
Catheterised
General UTI causing microbes
KEEPS
K- Klebsiella
E- E Coli (UPEC) (80% of cases)
E- Enterococci
P- Proteus spp
S- Staphylococcus
(Most common E Coli strain is UPEC (UroPathogenic E Coli))
Why are women more affected by UTIs
They have a shorter urethra, which is closer to the anus, allowing for easier microbial colonisation
Investigations in uncomplicated UTI
Midstream urine dipstick (leukocytes, nitrites, may or may not have haematuria)
Midstream urinary culture (MC and S - Microscopy, culture and sensitivity)
Treatment of uncomplicated UTI
Nitrofurantoin and trimethoprim (teratogenic) 3 days, while waiting for culture
Do not treat >65 years if asymptomatic
Define Pyelonephritis with risk factors
Infection of renal parenchyma and upper ureter, which can be direct or haematogenous
- Vesico-ureteral reflux
- Unprotected sex
- Female
- Pregnancy
- Urinary tract obstruction
- Indwelling catheter
- Ascending lower UTI
Signs/symptoms of pyelonephritis
TRIAD:
Fever, loin/back pain, pyuria (WBC in urine)
Renal angle tenderness, nausea/vomiting, haematuria
Abdo exam and Investigations in pyelonephritis
Abdominal exam
- Tender loin
- Renal angle tenderness
Midstream urine disptick
- Blood, protein, leukocyte, nitrites, foul smell
CT scan first line imaging
GOLD: Midstream urine MC+S
Management of pyelonephritis
IV fluids and broad spectrum antibiotics (Co-amoxiclav 14 days)
Drain obstructed kidney and remove catheter
Complications of pyelonephritis
Renal abscess
Emphysematous pyelonephritis (gas accumulation in tissues, life threatening)
Chronic pyelonephritis
How should catheterised UTI be investigated
DONT use urine dipstick.
Culture should come from catheter
Define cystitis
Usually UPEC infection of bladder
Signs and symptoms of cystitis
Suprapubic pain/tenderness, Dysuria (pain/burning when urinating), frequency, urgency, cloudy/smelly urine
How to diagnose cystitis
Abdominal exam
Urine dipstick and MC+S
Define urethritis
Urethral infection and inflammation, usually sexually acquired
Causes of urethritis
Infective
- Gonococcal (Neisseria gonorrhoea)
- Non gonococcal (chlamydia tractomatis)
Non infective
Trauma
Reactive arthritis
Signs/symptoms of urethritis
Urethral discharge (blood/pus), itching, irritation
Dysuria, frequency, urgency
Investigations in urethritis
1st - NAAT (Nucleic acid amplification test)
Females - vulvovaginal swab
Males - First void urine (first in morning)
Urethral discharge gram stain (Gram negative diplococci = N gonorrhoeae)
Urine dipstick and culture
Treatment of urethritis
N gonorrhoea
- Single dose of IM Ceftriaxone (1g) or oral ciprofloxacin (500mg)
Chlamydia
- Doxycycline 2x a day for 7 days
What should be looked at after pharmacological treatment in urethritis
Sexual abstinence
Safeguarding issues in children
Contact tracing
Disseminated Gonococcal Infection most common complication (skin and joints affected)
Define Epididymo-Orchitis
Inflammation of epididymis, extending to testes, usually secondary to urethritis (STI pathology) or Cystitis (Mostly UPEC)
Signs/symptoms and treatment of Epididymo-Orchitis
Unilateral scrotal pain and swelling.
Pain relieved with elevation of testes
cremaster reflex intact
Treatment will be identical to cystitis or urethritis depending on cause.
Define prostatitis
Severe prostate infection usually due to KEEPS pathology
Signs/symptoms of prostatitis
Tender hot swollen prostate on DRE
Pelvic pain
LUTS (Dysuria, frequency, hesitancy, urgency etc)
Pain with bowel movements
Infection symptoms (Tachycardia, fever, nausea, rigors etc)
Investigations of prostatitis
Digital rectal exam (DRE)
Urine dipstick and MSU (midstream urine sample) with culture
Blood culture
STI screen (NAAT)
Differentials of prostatitis (5)
BPH
UTI
Prostate cancer
Bladder cancer
Epididymo-orchitis
Management of prostatitis
Acute
- 14 day ciprofloxacin
analgesia and laxatives if pain
Chronic
- Alpha blockers (tamsulosin)
- 4-6 week doxycycline or trimethoprim
Complications of prostatitis
Main: Prostate abscess (especially if indwelling catheter)
Sepsis
Progression to chronic
Define Benign Prostatic Hyperplasia
Non malignant growth of the prostate gland, causing compression of the prostatic urethra causing Lower Urinary Tract Symptoms (LUTS). Usually affects transitional zone
What are some causes of fluid overload
Heart or kidney conditions
Pregnancy
Too much salt in diet/too much water intake
Liver failure (hypoalbuminaemia)
Conns
Pathophysiology of BPH
Luteinising hormone acts on leydig cells to produce testosterone
5a-reductase converts testosterone to dihydrotestosterone (DHT)
Androgens bind to androgen receptors, preventing apoptosis and allowing glandular epithelial cells and stromal cells (connective tissue) to grow.
With age, testosterone decreases but 5a-reductase activity increases leading to excess DHT, causing excess hyperplasia of the prostate.
This compresses prostatic urethra, causing build up of urine and difficulty voiding. This also causes bladder hypertrophy.
Signs/symptoms of BPH
LUTS Symptoms
Voiding: Hesitancy, weak stream, straining, dysuria, incomplete emptying, terminal dribbling.
Storage: Urgency, frequency, nocturia, incontinence
DRE findings in BPH
Smooth, enlarged, non tender prostate
Investigations in BPH
Digital rectal exam - Smooth, enlarged, non tender bladder
PSA Testing - raised in prostate cancer but can also be raised in BPH
IPSS score (international prostate symptom score) used
Urinary frequency volume chart
Pharmacological management of BPH with side effects.
1) Alpha-1-blockers - Tamsulosin (relaxes muscles in bladder to reduce resistance to bladder flow) (SE: Postural hypotension)
2) 5-alpha-reductase-inhibitors - finasteride (inhibit conversion of testosterone to dihydrotestosterone to reduce prostate size) SE: Sexual dysfunction
Surgical management of BPH with main side effect
Transurethral resection of the prostate (TURP)
Main side effect: Retrograde ejaculation, erectile dysfunction
Define prostate cancer with 4 risk factors
Adenocarcinoma of the prostate gland (usually peripheral zone).
Associated with BRCA1 and BRCA2
Age
Afro Caribbean
Family history
Signs/symptoms of prostate cancer
LUTS- Voiding: Hesitancy, weak stream, straining, dysuria, incomplete emptying, terminal dribbling.
Storage: Urgency, frequency, nocturia, incontinence
- Bone pain (if metastasised to bone)
- Wight loss, fatigue, night sweats
Investigations of prostate cancer
DRE: Hard, asymmetrical, nodule, irregular prostate with loss of median sulcus
PSA
Transrectal ultrasound
Prostate Biopsy - GOLD. Used with Gleason score.
Bone scan to check for bone metastasis (Lesions)
What scoring system is used in prostate cancer
Gleason scoring - Uses biopsy to grade prostate cancer
1-5
1 - Well differentiated cancer
5 - Anaplastic (Extremely poorly differentiated)
1st and 2nd most prevalent histological patterns graded and added together to give score out of 10.
Management of prostate cancer
Local - prostatectomy
Active surveillance if >70 or not severe
If metastatic
- Radiotherapy
- Hormone therapy (GnRH e.g. Goserelin) or bilateral orchidectomy (remove testicles) - reduce testosterone
- Androgen receptor blocker
Other causes of raised PSA
BPH
Prostatitis
UTI
Vigorous exercise
Recent ejaculation
Define Bladder cancer with 4 main risk factors
Transitional cell carcinoma of the bladder most common.
- Aromatic amines (Dyes/rubber)
- Polycyclic aromatic hydrocarbons (aluminium, coal)
- Bladder stones causing chronic inflammation
Signs and symptoms of bladder cancer
Painless haematuria
Weight loss
Palpable suprapubic mass
History of working in atrisk industries
Investigations of bladder cancer
Urinalysis - haematuria
CT Urogram - staging
Cystoscopy and biopsy GOLD
Management of bladder cancer
Chemo/Radio
TURBT (Transurethral resection of bladder tumour)
Define renal cell carcinoma
Clear cell Adenocarcinoma of proximal convoluted tubule most common
Kidney cancer of under 5s usually Wilms’ tumour
Main risk factor for RCC
von Hippel-Lindau. Autosomal dominant tumour suppressor gene loss.
Also
- Polycystic kidneys
- Renal failure
Signs/symptoms of RCC
Classic triad
- Haematuria
- Flank pain
- Weight loss
Left sided varicocele possible
Investigations and treatment of RCC
1st - USS
GOLD - CT Chest, abdomen, pelvis
Staging with Robson staging, TNM if metastatic
Treated with Nephrectomy
Define testicular cancer
Most common cancer in young men
Can be germ cell (Seminoma, Yolk sac tumour (Children) Teratoma) (90%) or non germ cell (Leydig cell, Sertoli cell) (10%).
Non hodgkin lymphoma also possible
Seminomas secrete b-hCG (make pregnancy test positive)
Signs/symptoms of testicular cancer
- Firm non-tender testicular mass that does NOT transilluminate.
- Supraclavicular lymphadenopathy
Signs of testicular cancer
- Firm non-tender testicular mass that does NOT transilluminate.
- Supraclavicular lymphadenopathy
Symptoms of testicular cancer with B-hCG pathology
- Hyperthyroid (B-hCG mimics TSH)
- Gynaecomastia
- Loss of libido
- Erectile dysfunction
- Testicular atrophy
What tells you its choriocarcinoma vs seminoma?
Choriocarcinoma presents younger and has a greater increase in bHCG
Investigation and tumour markers in testicular cancer
Testicular doppler ultrasound GOLD
B-hCG - Choriocarcinoma and Seminoma
AFP - Yolk sac tumour, Teratoma, Embryonal carcinoma
Management of testicular cancer (seminoma as MC)
Localised - Radical orchiectomy
Metastatic - Add chemo and radiotherapy (Just combination chemo if non seminoma)
Define autosomal recessive polycystic kidney disease with 3 signs and main investigation
Rare PKHD1 mutation which codes for fibrocystin. Disease of infancy.
Causes renal failure before birth.
- Clubbed feed
- Flat nasal bridge
- Underdeveloped lungs and ears
Prenatal ultrasound will show bilaterally large kidneys with cysts and oligohydramnios (low amniotic fluid).
Define autosomal dominant PKD
Mutations in PKD1 (C16) and PKD2 (C4), which code for polycystin 1 and 2. This causes cyst formation all over the kidney, making it appear larger
PKD1 more severe and earlier onset.
What do PKD1 and 2 code for, and what happens in their absence
In primary cilium, urinary filtrate passage cause cilium to bend. Polycystin 1 and 2 allow calcium influx, which activate pathways that inhibit cell proliferation.
In mutation, cells proliferate abnormally, and proteins attract water into lumen. This causes cyst growth which press on vessels causing ischaemia.
Hypoperfused kidneys cause activation of RAAS, leading to fluid retention and HTN.
Cysts can also press on collecting duct causing urinary stasis and kidney stones.
Eventually, enough renal damage occurs, leading to renal failure
What is the second hit mutation in PKD
In heterozygous ADPKD, enough polycystin 1 or 2 is produced to prevent PKD. In life, a “second hit” mutation causes the mutation to become homozygous, causing PKD
Extra renal cyst formations in PKD (5)
Polycystins found in other places, can cause cysts all over:
- Liver (polycystic liver)
- Aortic root (aortic regurgitation/heart failure)
- Berry aneurysm of cerebral artery/circle of willis, which can rupture causing subarachnoid haemorrhage
- Pancreas
- Seminal vesicles
Signs and symptoms of PKD
Signs:
Bilateral flank masses with flank pain
HTN
Symptoms:
Haematuria
Renal colic
Polyuria, polydipsia, nocturia (kidneys non responsive to ADH)
Investigations in PKD
Ultrasound - bilateral renal cysts
If positive family history >= 3 cysts diagnostic.
Management of PKD
Mainly targets symptoms/complications
HTN - ACEi
If severe, tolvaptan (Vasopressin 2 (V2) receptor antagonist) slows cyst development
Analgesia, dialysis, transplant
Complications of PKD (5)
Cyst rupture
Haemorrhagic cyst rupture/ haemorrhagic stroke!
Infection
Renal stones
HTN
Define Testicular Torsion
Emergency caused by twisting of the testicle on its spermatic cord, causing ischaemia and eventual necrosis.
6 hour window after onset until ischaemic damage is irreversible
4 risk factors for testicular torsion
Adolescent
Bell clapper deformity (high riding testicles with horizontal lie, due to failure to attach to tunica vaginalis)
Cryptorchidism (undescended testis)
Trauma
Signs and symptoms of testicular torsion
- Hard, swollen, high riding, tender testicle with horizontal lie.
- Absent cremasteric reflex
- Prehn’s negative - pain not relieved on lifting testicle (unlike epididymitis)
Sudden onset excruciating pain, may have nausea/vomit
TWIST score
What is the cremasteric reflex
Stroking of the inner thigh causes cremaster muscle to contract and pull ipsilateral testicle up towards the inguinal canal.
Investigations and management in testicular torsion
Emergency surgical exploration (waiting longer than 6 hours, irreversible damage likely)
If testicle is viable, Bilateral detorsion and orchidopexy (testicle untwisted and fixed to scrotal sac)
If unviable, orchiectomy and orchidopexy of other testicle
If testicular torsion surgery is delayed, what can be done in the meantime?
Manual detortion - temporary measure if surgery not possible in 6 hours.
Define Varicocele with 2 main causes
Dilated testicular veins in pampiniform plexus, 90% occur on left side. Give a “bag of worms” appearance
- Absent/defective valves
- Increased pressure in left renal vein (left sided only)
Normal blood supply of the testicles
Blood enters through testicular artery and leaves through the pampiniform plexus and then the testicular veins.
The left testicular vein drains into the left renal vein at right angle
The right testicular vein drains directly into the inferior vena cava
Pampiniform plexus helps manage temperature of testicles by absorbing heat through testicular artery
Pathophysiology of varicocele
Dilatation of pampiniform plexus due to increased pressure in testicular veins. Mostly left sided due to LTV being longer and joining at right angle.
RCC can cause obstruction of left renal artery increasing resistance in LTV, causing left sided varicocele
How are varicoceles graded
Subclinical - No clinical abnormality, but detectable by Doppler USS
Grade 1 (small) - Only palpable with Valsalva manoeuvre
Grade 2 (moderate) - Palpable without Valsalva
Grade 3 (Large) - Varicocele visible through skin
Valsalva manoeuvre - Exhale forcefully with mouth closed and nose pinched
Signs/symptoms of varicoceles
Palpable scrotal veins (bag of worms appearance)
Dilatation increased with Valsalva manoeuvre
Scrotal mass greater when standing, disappears when lying down
Affected testicle may be lower and smaller
May have dull/throbbing pain which is worse on standing
Investigations of varicoceles
Testicular examination standing and lying (bag of worms, worse standing, better lying, asymmetry of testicle size)
Doppler Ultrasound
Semen analysis may be done to check fertility
When might a varicocele warrant referral
- Sudden, painful onset
- Doesn’t drain when lying down
- Solitary on right side
What are the 2 types of scrotal cyst?
Hydrocele - serous fluid between parietal and visceral layers of tunica vaginalis (goes around testical)
Epididymal cyst - Smooth, extra testicular, spherical sac of fluid in epididymis (top of testicle). Generally harmless.
Two main types of hydrocele
Communicating (Primary) - failure of normal closure of processus vaginalis. Allows passage of peritoneal fluid into tunica vaginalis
Non communicating (Secondary)- No abnormal connection with peritoneal cavity. Fluid from mesothelial lining of t vaginalis. Can be secondary to:
- Testis tumours
- Trauma
- Infection (epididymo-orchitis)
- Testicular torsion
- TB
How does hydrocele present (3 points) and main 3 investigations
Scrotal swelling
- Smooth, non reducible, non tender
- Transilluminates
- Communicating is soft and fluctuates in size, non communicating stays the same size
- Pen torch illumination
- Physical examination
- Testicular ultrasound
Management of hydrocele
Mostly self limiting
Late onset non communicating may need surgery
- aspiration
- Lord’s or Jaboulay procedure
Define Epididymal cyst
Smooth, extra testicular sac of fluid at head of epididymis (top of testicle)
If it contains sperm it is called a spermatocele
How does Epididymal cyst present and give its management
Soft round lump at top of testicle.
Well defined and transilluminates
Most are asymptomatic but larger cysts can be painful or cause heaviness
- Usually self limit (10 days) and have no lasting effects.
- Surgical excision can be done if needed
Define Nephritic syndrome with its main symptoms
Non specific clinical picture of inflammation within the kidneys. Consists of;
- Haematuria
- Oliguria (low urine)
- HTN (Na+ retention) and oedema (fluid retention/overload)
- Slight Proteinuria BUT:
<3.5g of protein in 24 hours. (anymore = nephrotic)
Define Nephrotic syndrome with its main triad
Issue with filtration barrier due to damage to glomeruli. Pathology affecting podocytes in primary disease.
Triad is:
- Proteinuria (>3.5g in 24 hours)
- Hypoalbuminaemia (loss of albumin in urine)
- Peripheral oedema (loss of oncotic pressure)
(haematuria may be present but is minor)
Secondary causes of Nephrotic syndrome
Diabetes
Amyloidosis
Infection (Hep B/C, HIV)
Drugs (NSAID, gold, penicillamine)
Main 5 protein/serum constituent features of Nephrotic syndromes
Proteinuria >3.5g
Hypoalbuminaemia
Hypercoagulability (loss of anti-thrombin III)
Hyperlipidaemia (causes frothy urine)
Susceptibility to infection (Loss of Ig in urine)
Conditions involved in nephritic syndrome
PIGS
Post-strep glomerulonephritis
IgA nephropathy
Goodpasture’s
SLE nephropathy
Conditions involved in nephrotic syndrome
MFM
Minimal change disease
Focal segmental glomerulosclerosis
Membranous nephropathy
Define IgA nephropathy
Type 3 hypersensitivity reaction (antigen-antibody deposition)
Abnormal IgA immune deposits accumulate in mesangium of kidney, inciting immune response causing inflammation.
Pathophysiology of IgA nephropathy
IgA released in response to infection of mucosal lining, e.g. gastroenteritis or upper resp tract infection. IgG bind to them and the complex deposits in mesangium of kidney (Bowman’s capsule) activating alternative complement system. Inflammation of glomeruli occurs, causing blood to seep into urine.
If untreated leads to end stage renal failure
Signs/symptoms of IgA nephropathy
Haematuria
Oedema/Hypertension
Pink, red, “coke” coloured urine
Sore throat suggest URTI as recent trigger
Loose stools or abdominal discomfort suggests gastroenteritis
(usually within 2 days)
Investigations of IgA nephropathy
Urine Dipstick/urinalysis: Blood (if protein, less than 3.5g)
C3/C4 - C4 normal (normal pathway not activated), C3 may be low
Renal biopsy GOLD
- Immunofluorescence - IgA complex
- Light microscopy - Mesangial proliferation
- Electron microscopy - Immune complexes
Management of IgA nephropathy
ACEi/ARB
Corticosteroids if proteinuria present after 3-6 months
Main differential of IgA nephropathy
IgA vasculitis/ Henoch-Schonlein purpura
- Systemic and can be nephrotic too.
- Arthritis, skin lesions, Bloody stools, abdominal pain
Define post strep glomerulonephritis
Delayed complication of pharyngitis (sore throat) or skin infections caused by beta haemolytic Strep Pyogenes. (1-2 weeks after) (NB: IgA nephropathy is 1-2 days!)
Pathophysiology of post strep glomerulonephritis
Group A streptococci (Strep pyogenes) carry M protein virulence factor which allows them to evade host defence. IgM or IgG form immune complexes with antigen which deposit in glomerular basement membrane causing activation of complement and inflammation.
Type 3 hypersensitivity reaction.
Signs/symptoms of post strep glomerulonephritis
Haematuria
Oliguria
Peripheral oedema
Signs of recent infection / Sore throat history!!
Investigations in post strep glomerulonephritis
Throat/skin swab - recent step pyogenes
Anti streptolysin antibody
Renal biopsy GOLD
Immunofluorescence - IgG, IgM, C3 deposits “starry sky”
Light microscopy - Enlarged hypercellular glomeruli
E- Microscopy - Subepithelial deposits (humps)
Management of post strep glomerulonephritis
Penicillin (underlying strep)
ACEi/ARB for HTN
Furosemide if oedema
Define Goodpasture’s syndrome
Type 2 hypersensitivity reaction
AKA Anti-GBM (Glomerular Basement Membrane) disease.
Autoantibodies target type 4 collagen in glomerular and alveolar membrane causing both haematuria and haemoptysis (pulmonary haemorrhage)
Risk factors of Goodpasture’s
HLA-DR15
Smoking (haemorrhage more likely)
Oxidative stress
Signs/symptoms of Goodpasture’s
Lungs (present first)
- Cough, SOB, HAEMOPTYSIS
Kidneys
- Haematuria, proteinuria, oliguria, HTN (nephritic syndrome signs)
Systemic (lethargy, fever, weight loss etc) may also present
Investigations in Goodpastures
Anti-GBM positive, p-ANCA positive
Urinalysis
Protein:creatinine ratio to calculate eGFR
Chest CT
Management of Goodpastures
Corticosteroids
Plasmapharesis
Intubation/dialysis if damage reaches endstage
Define SLE Nephropathy with antibodies and treatment
Lupus nephritis secondary to SLE.
- Anti dsDNA, ANA
- Hydroxychloroquine, Prednisolone and immunosuppressant (azathioprine)
Refresher card: Define Nephrotic with its classical triad
Issue with filtration barrier due to damage to glomeruli. Pathology affecting podocytes in primary disease.
Triad is:
- Proteinuria (>3.5g in 24 hours)
- Hypoalbuminaemia (loss of albumin in urine)
- Peripheral oedema (loss of oncotic pressure)
Main 5 features of Nephrotic syndrome
Proteinuria >3.5g
Hypoalbuminaemia
Hypercoagulability (loss of anti-thrombin III)
Hyperlipidaemia (causes frothy urine)
Susceptibility to infection (Loss of Ig in urine)
Signs/symptoms of nephrotic syndrome
Proteinuria
Hypoalbuminaemia
Oedema
Frothy urine
Recurrent infection
Thromboembolic predisposition
Define Minimal change disease, age of onset and what makes it unique
Most common Nephrotic.
Aetiology unknown but associated with Hodgkin’s Lymphoma, leukaemia and NSAID use.
Usually occurs before the age of 8.
Immunoglobulins ARENT excreted in urine (Only Nephrotic with this feature)
Investigations in Minimal change disease
Kidney biopsy
Light microscopy - Normal
E- Microscopy - Podocyte effacement
Urinalysis has protein but no blood
Management of minimal change disease
High dose prednisolone
Define focal segmental glomerulosclerosis with causes
Focal - Only some glomeruli affected
Segmental - Only part of affected glomeruli affected
Sclerosis - Scarring
Can be idiopathic or secondary to
- HIV
- Heroin
- Lithium
- Lymphoma
Investigations in Focal Segmental Glomerulosclerosis
Light microscopy - sclerosis/hyalinosis
Management of FSG
Prednisolone + ACEi/ARB
Define Membranous nephropathy
Anti-PLA2R antibodies cause disease of glomerular basement membrane. GBM damage causes it to form expansions - “spike and dome” appearance.
Mostly affects white male adults.
Investigations of Membranous nephropathy
Anti-PLA2R antibodies
Light microscopy - GBM thickening
Electron microscopy - Subepithelial spike and dome pattern
Treatement of membranous nephropathy
Prednisolone + ACEi/ARB
What 2 diseases can be both nephritic and nephrotic
Diffuse proliferative glomerulonephritis
Membranoproliferative glomerulonephritis
What can be seen on microscopy in a patient with Nephrotic syndrome caused by diabetes
Light - Mesangial expansion, GBM thickening, Kimmelstiel-Wilson nodules
Caused by non enzymatic glycation
What hypersensitivity reactions are all the Nephritic syndromes?
All type 3 except Goodpastures
Goodpastures is type 2
Define diffuse proliferative glomerulonephritis with main investigation
Proliferation affecting >50% of the glomeruli, SLE Nephritis is an example of this. Presents with signs of both nephritic and nephrotic
Renal biopsy GOLD - “Wire loop” appearance due to immune complexes creating an overall thickening
Define Membranoproliferative glomerulonephritis with main investigations
Deposits in kidney mesangium cause thickening of it. (Membranous glomerulonephritis doesnt have mesangial thickening!!)
Renal biopsy shows “tram track” appearance
LUTS Symptoms to know!
Storage (FUNI)
- Frequency
- Urgency
- Nocturia
- Incontinence
Voiding (SHID)
- poor Stream
- Hesitancy
- Incomplete emptying
- terminal Dribbling
What muscle wraps around the bladder and controls urination?
The detrusor muscle
What allows the bladder to stretch and grow as it fills?
Umbrella cells in the transitional epithelium lining
Define Urge incontinence with cause
Overactive bladder causes sudden urge then involuntary urination due to involuntary, uninhibited detrusor contraction.
Usually due to UTI (infection may trigger detrusor muscle)
Define stress incontinence with causes
Acute increase in abdominal pressure overwhelms sphincter muscles.
Caused by pregnancy and exertion (sneezing, coughing, laughing)
Define overflow incontinence with causes
Bladder doesn’t empty properly so when it fills back up, it overflows and urine leaks through sphincters.
Usually due to nerve damage;
- Diabetes
- MS
- Syphilis
- Brain/spinal cord injury
Can be due to urinary flow blockage e.g. prostate hypertrophy
Define outlet incompetence with causes
Urethral hypermobility or intrinsic sphincter damage/deficiency means body cant stop urine passage
Give some causes of an inability to pass urine
Obstruction
- Stones
- BPH
- Flaccid paralysis
- Hypotonia of detrusor
2 types of drug which cause AKI through reduced renal perfusion
NSAID
ACEi
4 types of drug which cause intrarenal injury (acute tubular necrosis, interstitial nephritis)
Penacillamine
Penicillin
Rifampicin
Cephalosporins (Ceftriaxone)
4 drugs that cause obstructive post renal pathology of the kidney
Sulfonamides (trimethoprim)
Methotrexate
Tricyclic antidepressants
Alcohol
Morphology of chlamydia causing bacteria
Gram negative coccoids (No peptidoglycan in cell wall)
What is the most common STI and what bacteria causes this?
Chlamydia
Chlamydia trachomatis
Presentation of chlamydia
Women
- Abnormal discharge
- Dysuria
- Intermenstrual bleeding
- Pain during sex
Men
- Urethral discharge
- Dysuria
- Epididymo-orchitis
- Reactive arthritis
Can also have effects on bowels (change in habit, bleeding, discharge)
Investigations of chlamydia
Swab (women) or MSU (men)
+ Nucleic Acid Amplification Test (NAAT) diagnostic
Management of chlamydia
Doxycycline for 7 days.
CI in pregnancy, so give Azithromycin 1mg STAT and 500mg for 2 days after.
Causative bacteria of gonorrhoea with its morphology
Neisseria gonorrhoea - gram negative diplococcus
How does gonorrhoea present
Odourless green/yellow discharge
Dysuria
Pelvic pain (epdidymo-orchitis in men)
Investigations in gonorrhoea
NAAT
Management of gonorrhoea
IM ceftriaxone single dose
What else can chlamydia and gonorrhoea cause
- Conjunctivitis
- Prostatitis
- Chronic pelvic pain/ inflammation
- Urethral strictures
- Rectal infection
Gonorrhoea can cause disseminated gonococcal infection
What bacteria causes syphilis
Treponema pallidum - gram negative
Disease course of syphilis
Incubation period - 21 days
Primary - Painless ulcer at site of infection
Secondary - Systemic symptoms for 3-12 weeks
- condylomata lata (grey wart like lesions on genitals)
- Maculopapular rash on palms, soles, trunk
- Fever
- Alopecia
Latent - 2 years
Tertiary
- Granulomatous lesions
- Aortic aneurysms
- can cause brain symptoms
Treatment of syphilis
Single IM dose of benzathine penicillin or doxycycline
How else can syphilis be passed?
From mother to child!
