RENAL/GENITOURINARY Flashcards

Question

Outline some advice given for people with recurrent stones.

Answer 1

- **Increase oral fluids** - **Reduce dietary salt intake** - **Reduce intake of oxalate-rich foods for calcium stones** (e.g. spinach, nuts, rhubarb, tea) - **Reduce intake of urate- rich foods for uric acid stones** (e.g. kidney, liver, sardines) - **Limit dietary protein**

Answer 2

Potassium citrate, **Thiazide diuretics** (e.g., indapamide) in patients with calcium oxalate stones and raised urinary calcium

Answer 3

Acute Kidney injury - Deterioration in renal function, **rise in serum creatine and urea,** …Due to a **rapid decline in GFR** ==> Leads to failure to maintain fluid/electrolyte homeostasis Decrease in function <3 months

Answer 4

one of the following parameters: - **An increase in serum creatinine by ≥ 26.5 micromol/L within 48 hours** - **An increase in serum creatinine to ≥ 1.5 times baseline within 7 days** - **Urine output < 0.5 mL/kg/hr for six hours**

Answer 5

Pre-renal – reduced blood flow to kidney leading to a falling GFR Renal – kidney can’t filter blood properly, cells damaged so reabsorption/secretion impaired Post-renal – anything that can cause blockage of kidney reducing outflow

Answer 6

*Reduced blood flow to kidney leading to a falling GFR* **Shock, + Hypovolaemia (fluid loss)** - this could be due to burns, sepsis, acute haemorrhage *trauma or bleeding*, anaphylaxis Decompensated Liver disease- Hepatorenal syndrome GI losses – diarrhoea and vomiting CV – severe HF, arrhythmias Renal artery/vein thrombosis/stenosis Renal hypoperfusion – NSAIDs, ACE-I, ARBs

Answer 7

Liver cirrhosis leads to portal hypertension In response to this, **portal blood vessels dilate,** stretched by large amounts of blood pooling there. This leads to a loss of blood volume elsewhere, including kidneys. Leads to **hypotension in the kidney and activation of the RAAS.** This causes renal vasoconstriction, which combined with low circulation volume leads to starvation of blood to the kidney *Hepatorenal syndrome is fatal within a week or so unless liver transplant is performed*

Answer 8

**Acute tubular necrosis** – *tubule damage following prolonged ischaemia* (often following pre-renal AKI) **Nephrotoxic drugs** **Glomerulonephritis** **Acute interstitial nephritis** **Infection** **Vasculitis** – *e.g. in SLE, affects renal arteries, arterioles and glomerular capillaries* **Malignant hypertension**

Answer 9

NSAIDs – inhibits COX which causes excess vasoconstriction of afferent arteriole Aminoglycosides - eg gentamicin – 10-15% incidence of ATN ACE-I/ARBs – results in dilated efferent arterioles decreasing GFR Methotrexate Gentamicin ***DAMN = (diuretics, ACEi/ ARBs, metformin, NSAIDs)***

Answer 10

NSAIDs reduce prostoglandin production * prostoglandins cause vasodilation of the afferent arteriole hence their inhibition causes vasoconstriction of the afferent arterioles * this cases reduced perfusion and hence reduced eGFR

Answer 11

Anything that can cause blockage of kidney reducing outflow Benign Prostate Hyperplasia Kidney stones in kidney, ureters, bladder, urethra Cancer Ovarian, colon, bladder cancer pushing on ureters or urethra Blood clot

Answer 12

Age - >75 years Diabetes Mellitus HF Sepsis Peripheral vascular disease Family history Drugs Poor fluid intake/fluid loss

Answer 13

Early stages often asymptomatic Oliguria – decreased urine output Anuria Dehydration Nausea and vomiting Confusion Fever (sepsis) Uraemia – weakness, tremor, fatigue, nausea, vomiting, mental confusion, seizures and coma Breathlessness – combination of anaemia and pulmonary oedema secondary to volume overload

Answer 14

**IT DEPENDS ON THE CAUSE/TYPE OF AKI** Pre Renal: Thirst Cool extremities Dizziness, Confusion Signs of fluid loss: excessive sweating, vomiting, diarrhoea and polyuria - **Dyspnoea** - **Raised JVP** **Intrinsic renal** - **Vascular:** arterial hypertension; peripheral oedema Nephritic syndrome: haematuria; - **Post-renal** - **Urinary stones:** loin-to-groin pain, haematuria, nausea and vomiting. - **Prostatic issues:** dysuria, frequency, terminal dribbling, hesitancy General symptoms: Tachycardia peripheral oedema Hypertension Poor tissue turgor Postural hypotension (dehydration) Fluid overload + ↑JVP, pulmonary oedema (CXR),

Answer 15

**Urine dipstick** - may see RBCs, WBCs, cellular casts, proteinuria, positive nitrite -- *all of these may suggest glomerulonephritis* Bloods – acutely elevated serum creatinine, **high serum potassium,** metabolic acidosis. LFTs will be deranged in hepatorenal syndrome Renal ultrasound – for obstruction Gives assessment of renal size – very small indicates CKD

Answer 16

Monitor urine output Non-contrast CT KUB KUB XR Urine and blood cultures to exclude infection Autoantibodies – Anti-GBM, ANCA

Answer 17

Can be classed as either Stage 1 - Creatine **rise 1.5-2 fold** from baseline, and or **<0.5ml/kg/hr** urine output for more than **6 hours** Stage 2 - Creatine rise **2-3 fold** from baseline, and or **<0.5ml/kg/hr** urine output for more than **12 hours** Stage 2 - Creatine rise **>3 fold** from baseline, and or **<0.3ml/kg/hr** urine output for **more than 24 hours**

Answer 18

3 THINGS - 1. **IV stat of Calcium Gluconate** - Stabilisation of the myocardium 2. **Variable rate insulin with dextrose infusion - to increase cellular uptake of potassium** = Reduction of serum potassium 3. **oral calcium resonium** - Reduction of total body potassium - treat underlying cause

Answer 19

Treat underlying cause - **Regular monitoring:** fluids, urine output, daily weights, baseline creatinine, serial U&Es - **Cease nephrotoxic drugs** - Hypovolaemia: **IV fluids** - Hypervolaemic: **fluid restriction and diuretics e.g. furosemide** - Obstruction: **catheter insertion; surgery to relieve obstruction** ***TREAT COMPLICATIONS*** - Hyperkalaemia, pulmonary oedema, uraemia, acidaemia - **Bicarbonate**

Answer 20

Dialysis – removal of toxic products in body for patients with failed kidneys. refer to critical care, get specialist involved!! Use of a vasopressor, ie **Noradrenaline** Consider the need for an inotrope **(e.g., dobutamine)** to optimise cardiac output if kidney hypoperfusion is caused by impaired cardiac function due to poor left ventricular systolic function

Answer 21

- **Hyperkalaemia:** when the individual is oliguric, potassium isn’t effectively removed from the blood. -- can lead to Cardiac arrest - **Fluid overload** - **Metabolic acidosis** - **Uraemia** - **Uraemic complications:** e.g. encephalopathy, pericarditis **RHABDOMYOLYSIS**

Answer 22

RENAL DR 26 Record baseline creatine Exclude obstruction Nephrotoxic drugs - stop Assess fluid status Losses - Measure fluid losses, with catherization Dipstick Review medications 26 - rise in creatine over 48 hours for AKI diagnosis

Answer 23

Chronic kidney disease (CKD) describes a progressive deterioration in renal function. These issues develop over at least 3 months.

Answer 24

By GFR and by the degree of **persistent Albuminuria** Goes G1-G5 and A1-A3

Answer 25

1 >90 Normal or increased GFR with other evidence of renal damage* 2 60–89 Slight decrease GFR with other evidence of renal damage* 3 A - 45–59, 3 B - 30–44 = Moderate decreased GFR with or without evidence of other renal damage 4 15–29 Severe decreased GFR with or without evidence of renal damage 5 <15 Established renal failure

Answer 26

The **A score** is based on the **a**lbumin:creatinine ratio: - A1 = < 3mg/mmol - A2 = 3 – 30mg/mmol - A3 = > 30mg/mmol

Answer 27

- Albuminuria (ACR > 3 mg/mmol) - Electrolyte and other abnormalities due to renal dysfunction (e.g. hyperkalaemia) - Structural abnormalities on imaging - A history of kidney transplantation

Answer 28

- Over 10% of the general population are thought to suffer from CKD - Rise in prevalence probably due to an ageing population and the rise in chronic diseases such as diabetes and hypertension

Answer 29

In CKD, The initial failing and scarring of some nephrons leads to an increased filtration on the remaining **Functioning, (remnant) nephrons** These remnant nephrons experience **hyperfiltration** (increased flow per nephron as blood flow remains the same), ==> adapt with **glomerular hypertrophy, and reduced arteriolar resistance**

Answer 30

Increased flow, increased pressure and increased shear stress causes a vicious cycle of **raised intraglomerular capillary pressure** and strain, which accelerates remnant nephron failure This increased **flow and strain** may be detected as **new/increasing proteinuria**

Answer 31

Elderly Ileostomy/colostomy Short bowel syndrome Bowel obstruction Diuretics

Answer 32

AKI Chronic kidney disease Heart failure Liver Failure

Answer 33

Hypertension (second most common) Diabetes (most common)

Answer 34

Walls **thicken in order to withstand pressure** 🡪 less blood and O2 to kidney 🡪 ischaemic injury to glomerulus Diminishes ability for nephron to filter blood

Answer 35

Excess glucose in blood stick to proteins (particularly affects **efferent arteriole making it stiff and narrow** Creates **obstruction for blood to leave glomerulus 🡪 hyperfiltration** 🡪 supportive mesangial cells secrete more structural matrix increasing size of glomerulus Glomerulosclerosis 🡪 CKD

Answer 36

Immune cells (macrophages and foam cells) slip into damaged glomerulus and release **TGF-B1** 🡪 mesangial cells regress to immature **mesangioblast and secrete extracellular matrix** 🡪 glomerulosclerosis (hardening and scarring) Diminishes ability for nephron to filter blood

Answer 37

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

Answer 38

Diabetes Hypertension Age Gender – M

Answer 39

Can be asymptomatic early on - **Nausea** - **Anorexia** - **Loss of appetite** - **Frothy urine** Malaise, oliguria, - *decreased urine output* haematuria, nocturia

Answer 40

- **Swollen ankles/ oedema** - **Increased bleeding:** excess urea in the blood makes platelets less likely to stick to each other Bone disease – osteomalacia, osteoporosis - ***Less 1, 25-dihydroxyvitamin D from kidneys = less Serum calcium - more PTH and bone remodelling** Lethargy - due to anaemia

Answer 41

- **Hypertension** - **Fluid overload** - **Uraemic sallow:** a yellow or pale brown colour of skin - **Uraemic frost:** urea crystals can deposit in the skin - **Pallor:** due to anaemia - **Evidence of underlying cause:** e.g. butterfly rash in lupus Bilaterally small kidneys on ultrasound Postural hypotension Peripheral oedema Pleural effusions

Answer 42

FBC – shows anaemia, raised creatinine and urea, decreased Ca2+, raised phosphate, PTH, K+ and renin Estimated glomerular filtration rate (eGFR), checked with U and E blood test Urinalysis, on dipstick = Haematuria and proteinuria suggest GN Leukocytes and nitrites suggest infection Mid-stream urine sent for microscopy and sensitivity Albumin to creatinine ratio (ACR)

Answer 43

Renal ultrasound – excludes obstruction, gives assessment of kidney size (small kidneys favour CKD) and also looks for other abnormalities such as cysts and masses

Answer 44

Pallor/pale skin Pulmonary/peripheral oedema (anasarca – oedema everywhere) Hypertension Pericarditis/pleural effusion **Retinopathy** Palpable kidneys and/or **renal bruit** (narrowing of renal vessels) **Uraemic smell**

Answer 45

Treat underlying cause Antibiotics for sepsis Correct volume depletion with fluids Immunosuppressive agents for vasculitis Treat hypertension Give statins Tight metabolic control in diabetes Stop nephrotoxic drugs

Answer 46

Diet – Na+ and K+ restriction, supply Vitamin D - **need to reduce CKD Mineral bone disease, by REDUCING SERUM PHOSPHATE AND PTH LEVELS** Smoking Alcohol Exercise

Answer 47

A – ACE-Inhibitor (e.g. Ramipril) or Angiotensin II receptor blocker e.g. valsartan B – Beta Blocker e.g. bisoprolol C – Calcium channel blocker e.g. amlodipine D – Diuretic e.g. oral Bendroflumethiazide **ACE-Inhibitors – reduce urinary protein** Half urinary protein = half chance of kidney failure and dialysis First line treatment in patients who are proteinuric and diabetic

Answer 48

**Serum potassium needs to be monitored as chronic kidney disease and ACE inhibitors, both cause hyperkalaemia.** *NOTE: do not routinely offer a renin–angiotensin system antagonist in CKD if the pretreatment potassium is > 5 mmol/L.*

Answer 49

**SGLT -2 inhibitors like dapagliflozin are particularly used in CKD** - USED IN PATIENTS WITH HEART FAILURE As it decreases renal intraglomerular pressure and inhibits the renin-angiotensin-aldosterone system.

Answer 50

**Cardiovascular** - Heart failure **MSK** - Metabolic bone disease, lowered Calcium and Raised Phosphate and PTH **Endocrine** - Secondary hyperparathyroidism, and tertiary **Haematological** - Anaemia - due to low EPO (Normocytic) or low Iron (Microcytic) **Metabolic** - Acidosis, Hyperkalaemia, uraemia - *Neuropathy, Encephalopathy, pericarditis*

Answer 51

Oral **sodium bicarbonate to treat metabolic acidosis** **Iron supplementation and erythropoietin** to treat anaemia Vitamin D to treat renal bone disease Dialysis in end stage renal failure Renal transplant in end stage renal failure

Answer 52

Dialysis – the removal or “uraemic toxins” from the blood by diffusion across a semi-permeable membrane towards low concentrations present in dialysis fluid Haemodialysis Surgical construction of AV fistula in forearm – join an artery and vein to make large vessel Peritoneal dialysis – involves infusing a sugary solution into the abdomen which draws off toxins Water moves across from circulation into PD fluid by diffusion

Answer 53

Symptomatic uraemic including pericarditis or tamponade Hyperkalaemia not controlled by conservative means Metabolic acidosis Fluid overload resistant to diuretics If this feels, do kidney transplant

Answer 54

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

Answer 55

Predominantly affects females under 35 yrs - **Vesico-ureteral reflux (VUR)** - (urine refluxing from the bladder to the ureters – usually in children) - **Female sex** - **Sexual intercourse** - **Indwelling catheter** - **Diabetes mellitus** - **Pregnancy** - **Urinary tract obstruction e.g. calculi (stones)**

Answer 56

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

Answer 57

Escherichia coli is the most common cause, as with lower urinary tract infections. E. coli are gram-negative, anaerobic, rod-shaped bacteria that are part of the normal lower intestinal microbiome. It is found in faeces and can easily spread to the bladder.

Answer 58

Other causes: Klebsiella pneumoniae (gram-negative anaerobic rod) Enterococcus Pseudomonas aeruginosa Staphylococcus saprophyticus Candida albicans (fungal)

Answer 59

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** = urine moves back up urinary tract due to a failure in the vesicoureteral orifice

Answer 60

- Obstruction also leads to urinary stasis, which makes it **easier for bacteria to adhere and colonise the urinary tract** - The infection can also occur via **haematogenous spread** - through the bloodstream, although this is a lot less common.

Answer 61

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

Answer 62

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

Answer 63

Patients also can present with increased white blood cells in their blood, called leukocytosis, and as a result of the inflammatory immune response, patients can also develop **fevers, chills, nausea and vomiting, as well as flank pain at the costovertebral angle.** Rare to get these in a lower UTI

Answer 64

- **Urine dipstick** - Blood - Protein - Leukocyte esterase (produced by neutrophils) - Nitrite (gram negative organisms metabolise nitrates in the urine to nitrites) - Foul smelling urine - **Bloods:** - Elevated WCC - CRP and ESR may be raised in acute infection - **Imaging** - CT scan can help confirm the diagnosis - Ultrasound scans are useful in children to confirm diagnosis and investigate long term damage after recovery

Answer 65

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

Answer 66

- **Lower UTI** - **Cystitis** - **Acute prostatitis** - **Urethritis** - **Chronic pyelonephritis**

Answer 67

- **Broad spectrum antibiotics (e.g. co-amoxiclav)** , **and Cefalexin for 7 to 10 days** until culture and sensitivities are avaliable - **Hydration** - Other/ adjuncts - **Admission** if systemically unwell or complicated - **IV rehydration** - **Analgesia** - **Antipyretics**

Answer 68

Renal abscess Recurrent infections Chronic pyelonephritis- Papillary necrosis

Answer 69

Chronic Pyelonephritis - recurrent infections of kidneys Can lead to **scarring/thinning of parenchyma,** and can progress to CKD/End stage renal failure

Answer 70

**Dimercaptosuccinic acid (DMSA) scan** Involves Injecting radiolabeled DMSA, which builds up in healthy kidney tissue. When imaged **using gamma cameras**, it indicates scarring or damage in areas that do not take up the DMSA - can assess for renal damage **Think of the band, the DMAs**

Answer 71

A lower UTI that involves the bladder

Answer 72

Post-menopause the absence of oestrogen increases the risk Sexual intercourse Diabetes - hyperglycaemia prevents neutrophils from carrying out their function against an infection Poor bladder emptying- allows the bacteria to adhere and colonise the bladder Catheterisation

Answer 73

- **E.coli** (most common) - **Staphylococcus saprophyticus**: approximately 5–10% of cases - **Proteus mirabilis**: more common in males, associated with renal tract abnormalities, particularly caliculi - **Klebsiella** - **Candida**: a rare cause and usually associated with indwelling catheters,

Answer 74

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.

Answer 75

**urine is normally sterile** - composition of urine, which has a **high urea concentration and low pH,** helps keep bacteria from setting up camp. The **unidirectional flow in the act of urinating** also helps to keep bacteria from invading the urethra and bladder. Some bacteria, though, are better surviving in and resisting these conditions, and can **stick to and colonise the bladder mucosa.**

Answer 76

Suprapubic tenderness - **Dysuria:** discomfort, pain, burning or stinging associated with urination - **Frequency:** - **Urgency:** - Changes in urine **appearance/consistency**: - **A cloudy or pungent odour** - **Haematuria** - **Nocturia:** passing urine more often than usual at night - Non-specific, generalised clinical features: e.g. **delirium, lethargy, reduced appetite** - **Delirium and confusion** especially common in elderly patients

Answer 77

- **Urine dipstick**: nitrite and leukocyte usually positive: - **Positive** nitrite **OR** leukocyte, **AND** positive RBCs: UTI is **likely** - **Negative** nitrite **AND** positive leukocyte: UTI is **equally likely** to other diagnoses - **Mid-stream urine microscopy, culture and sensitivity (MC&S)**: - Gold standard - The most specific and sensitive test; bacteria, WBCs, +/- RBCs expected

Answer 78

First line: Antibiotic course for 3 days - **nitrofurantoin or trimethoprim** Second line: Antibiotic course for 3 days - nitrofurantoin or pivmacillinam or fosfomycin single-dose sachet

Answer 79

First line: Antibiotic course for 7 days - nitrofurantoin **but avoid nitrofuratnoin in third trimester, give a penicllin instead** Second line: Antibiotic course for 7 days - amoxicillin or cefalexin (1st Gen Cephalosporin)

Answer 80

First line: Trimethoprim 200 mg twice a day for 7 days Second line - Nitrofurantoin: If not resolving, consider an alternative diagnosis !

Answer 81

Trimethoprim carries a teratogenic risk in the first trimester as it inhibits folate synthesis. Although Nitrofurantoin is first line in pregnant women with lower urinary tract infections, it should be **avoided at term as it may cause neonatal haemolysis**

Answer 82

Pre-term delivery Low-birthweight

Answer 83

Aged 45 years and over and have: Unexplained visible haematuria **without urinary tract infection,** or Visible haematuria that persists or recurs after successful treatment of urinary tract infection, Aged 60 years and over and have **unexplained non-visible haematuria and either dysuria or a raised white cell count** on a blood test. Consider non-urgent referral for bladder cancer in people aged 60 years and over with recurrent or persistent unexplained urinary tract infection.

Answer 84

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

Answer 85

E.coli most common STI’s Catheter Disseminated infections- *Secondary to a disseminated infection Bacteria like S.aureus may exhibit ‘metastatic’ spread to multiple locations.* ***Trauma causing nerve damage is a key risk factor for chronic prostatitis***

Answer 86

STI UTI Indwelling catheter Post-biopsy Increasing age ***Trauma causing nerve damage is a key risk factor for chronic prostatitis***

Answer 87

- **Tender, hot, swollen prostate** (on digital rectal exam) - **Palpable bladder** (if urinary retention) - UTIs, retention, pain, haematospermia, swollen/boggy prostate on DRE **Pyrexia** Rigors

Answer 88

Systemically unwell - **Perineal, rectal or pelvic pain** - **Back pain** Fever Rigors Malaise Painful ejaculation **Voiding LUTS** - ***Lower urinary tract symptoms***: - Straining - Poor stream - Incomplete emptying - Hesitancy - Post-micturition dribbling - Dysuria

Answer 89

**Digital Rectal Examination** - Prostate is tender, Hard from calcification **Urine dipstick** – positive for leucocytes and nitrites MSU microscopy, culture and sensitivity Blood cultures STI screen – chlamydia in particular Trans-urethral ultrasound scan (TRUSS)

Answer 90

First line- Oral ciprofloxacin or ofloxacin -- ***fluoroquinolones*** Second line- Oral levofloxacin or co-trimoxazole or according to BMJ, piperacillin/tazobactam

Answer 91

TRUSS *(Transrectal Ultrasound)* guided abscess drainage, if needed - If patient presents with sepsis, patient must be treated according to **sepsis 6 principles.** - Patients require further urological review after the acute episode is treated to evaluate for pre-disposing structural abnormalities in the urinary tract.

Answer 92

by > 3 months of urogenital pain, often associated with LUTS or sexual dysfunction. ***- Those with underlying urinary tract abnormalities are at greater risk.*** - Men with HIV are at risk of a greater breadth of infection.

Answer 93

- **Analgesia** - Paracetamol - NSAIDs with PPI cover - **Stool softeners** may offer some relief. - **Referral to pain team specialist** may be needed, particularly if neuropathic pain is considered. - **Alpha-blockers (e.g. Tamsulosin)** may be trialled if significant LUTS are present. Referral to urology Antibiotic course, cause is bacterial.

Answer 94

Urethral inflammation due to infectious or non-infectious causes Non-gonococcal urethritis more common than gonococcal

Answer 95

**Gonococcal** Neisseria gonorrhoea **Non-gonococcal** Chlamydia – most common Mycoplasma genitalium Trichomonas vaginalis - ***A flagellate protozoa*** **Non-infective** Trauma Urethral stricture Irritation Urinary calculi (stones)

Answer 96

Chlamydia *Certain house mate has this*

Answer 97

Gonococcal and non-gonococcal

Answer 98

Neisseria gonorrhea

Answer 99

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

Answer 100

Male to male sex Unprotected sex multiple sexual partners

Answer 101

Urethral discharge Urethral irritation/itching Dysuria Penile discomfort Skin lesions

Answer 102

**Nucleic acid amplification test (NAAT)** Female – self-collected vaginal swab, endo-cervical swab, first void urine Male – first void urine *High specificity and sensitivity* **Microscopy of gram-stained smears of genital secretions** **Blood cultures** Urine dipstick – to exclude UTI Urethral smear

Answer 103

**1-week oral doxycycline** *(a tetracycline)* Pregnant – oral erythromycin (14 days) or oral azithromycin

Answer 104

IM ceftriaxone (3RD GEN cephalosporin) Partner notification

Answer 105

CAN SPREAD = Epididymitis, Prostatitis Reactive arthritis Gonococcal conjunctivitis Periurethral abscess Urethral stricture or fistula

Answer 106

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

Answer 107

STIs, eg Chlamydia trachomatis Neisseria gonorrhoea mycoplasma genitalium

Answer 108

Over 35 UTI – KEEPS Klebsiella E. Coli – most common Enterococcus Pseudomonas Staphylococcus – coagulase negative

Answer 109

Mumps (viral) Trauma Elderly – predominantly catheter related

Answer 110

Subacute onset of unilateral scrotal pain and swelling **STI Epididymo-orchitis,** eg Urethritis, Urethral discharge **Mumps** eg - Headache, Fever, Unilateral/bilateral parotid swelling Tenderness Sweats/fever Signs - Tenderness and palpable swelling

Answer 111

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

Answer 112

- **Urinalysis:** first void sample is most useful and should be sent for microscopy and culture. - **Nucleic Acid Amplification Test (NAAT):** first void urine sample for NAAT to detect the DNA/RNA of the causative organism - **Swab of urethral secretions**: less sensitive than NAAT ****but must also be performed in symptomatic men

Answer 113

Fluoroquinolone e.g., ofloxacin or ciprofloxacin

Answer 114

Empirical: ceftriaxone and doxycycline Basically the treatment for Gonorrhoea

Answer 115

- **Musculoskeletal**: reactive arthritis secondary to chlamydia or gonorrhoea - **Infective**: disseminated infection secondary to gonorrhoea - **Reproductive**: male subfertility or infertility - **Urological:** epididymal obstruction and scarring secondary to poorly treated infection

Answer 116

Uncomplicated – non-pregnant females Not necessary to send MSU and treat empirically 3 days If MSU sent – adjust antibiotics accordingly Adjunctive advice Increase fluid intake Void pre-post intercourse Hygiene

Answer 117

Pregnant females Males Catheterised patients Children Recurrent/persistent infection Immunocompromised Nosocomial infection Structural abnormality Urosepsis Associated urinary tract disease

Answer 118

Glomerulonephritis refers to groups of parenchymal kidney diseases that all result in the inflammation of glomeruli and nephrons

Answer 119

Nephrotic syndrome – protein leaks due to inflammation of podocytes Acute GN (nephritic syndrome) – blood vessels inflamed 🡪 blood leaks out Rapidly progressive GN – features of acute nephritis, focal necrosis and rapidly progressing renal failure

Answer 120

Histologically, capillaries have 3 components: Epithelium – composed of podocytes which only makes contact with GBM via foot processes Glomerular BM Fenestrated endothelium – lining of capillaries Mesangial cells holding it all together

Answer 121

According to the National Kidney Foundation, normal results range from **90 to 120 mL/min** Older people will have lower than normal GFR levels, because GFR decreases with age.

Answer 122

Nephritic syndrome or acute nephritic syndrome refers to a group of symptoms, not a diagnosis. These symptoms are caused inflammation that damages the glomerular basement membrane, can be due to a number of different causes.

Answer 123

- **Haematuria** - **Proteinuria** - **Arterial hypertension** - **Peripheral and peri-orbital oedema** - swelling around eyes - **Decreased urine output**

Answer 124

Nephritic syndrome can be differentiated from nephrotic syndrome because the proteinuria is generally under 3.5 grams per day, or within the “sub-nephrotic range”.

Answer 125

* Goodpasture’s syndrome * IgA nephropathy (Berger disease) - Post-strep glomerulonephritis * SLE nephropathy GAPS

Answer 126

is defined by the presence of mesangial IgA immune deposits, often accompanied by C3 and IgG in association with a **mesangial proliferative** glomerulonephritis of varying severity. Formerly called **Berger’s disease**. - sounds like he was a barrel of laughs

Answer 127

80% diagnosed between 16 and 35. More common in Asian population IgA nephropathy remains the most common glomerulonephritis in the developed world.

Answer 128

Tend to develop from infection of mucosal lining, or **respiratory tract** **IgA antibodies are mainly secreted by the mucosal tissues of the respiratory and GI tract, so IgA nephropathy usually accompanies a respiratory or a GI infection.**

Answer 129

1. In IgA nephropathy - **No Glycosylation with Galactose** like IgA antibodies normally are - So not recognised and degraded like normal, so **too much accumulates** 2. Because the IgAs are foreign, body **Generates IgG antibodies**, forming immune complexes = **(Anti-glycan autoantibodies)** 3. These Anti-glycan autoantibodies **deposit in the Mesangium** 4. Here, these activate the **ALTERNATIVE COMPLIMENT PATHWAY** - release of proinflammatory cytokines and migration of macrophages into kidney

Answer 130

- **Haematuria** - Macroscopic: particularly in younger patients - Microscopic: particularly in older patients - **Oedema:** due to proteinuria - **Cervical lymphadenopathy:** suggests an URTI as a recent trigger - **Hypertension**

Answer 131

Think of trigger infections - GI or RESP - **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 trigger

Answer 132

- **Urine dipstick:** blood and protein would be expected - **U&Es:** allows the assessment of baseline renal function, as well as monitoring for deterioration - **C3 and C4 levels:** C4 will be normal as the classical complement pathway is **not** activated by IgA nephropathy. However, **C3 can either be low or normal** depending on the extent of alternative pathway activation. ***Renal biopsy: definitive diagnostic investigation***

Answer 133

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

Answer 134

**IgA vasculitis, also known as 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. Therefore on Light/electron microscopy and immunofluorescence, you would see the same things.

Answer 135

- **ACE-inhibitor/ARB:** BP control - **Corticosteroids:** offer a 6-month trial if there is persistent proteinuria despite 3-6 months of an ACE inhibitor or ARB - **Statins:** control of high cholesterol has been shown to slow kidney damage - **Omega-3 fatty acids**: available in dietary fish oil, these supplements reduce glomerular inflammation; offer if there is persistent proteinuria despite 3-6 months of an ACE inhibitor or ARB

Answer 136

Post-streptococcal glomerulonephritis (PSGN) is usually an immunologically-mediated **delayed consequence of pharyngitis or skin infections** caused by streptococcus pyogenes

Answer 137

- Most frequently seen in children - Usually develops 1-2 weeks after URTI (upper respiratory tract infection)

Answer 138

Some strep A strains carry the **M-protein virulence factor which initiates a type III hypersensitivity reaction.** IgG and IgM antibodies form immune complexes - **Anti DNAase B** - specifically These immune complexes travel to the glomerulus through the blood and deposit in the glomerular basement membrane.

Answer 139

Anti DNAase B

Answer 140

- Most of the time they’re ***subepithelial: between the podocytes and the basement membrane.*** - The immune complexes initiate an inflammatory reaction in the glomerulus, which involves activation and deposition of C3 complement, inflammatory cytokines, oxidants, and proteases that damage the podocytes.

Answer 141

Haematuria Recent strep infection

Answer 142

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

Answer 143

- **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 144

Supportive. - **Furosemide:** for initial treatment of hypertension - **Antibiotics**

Answer 145

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

Answer 146

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

Answer 147

Cells have faulty DNA, and when these faulty cells undergo apoptosis, these are released and become **nuclear antigens** immune cells recognise them as forgein and create **antinuclear antibodies that bind to them.** These can travel in the blood and get stuck in lungs, joint, skin, CNS, Heart Kidneys etc

Answer 148

It is a type III hypersensitivity reaction where immune complexes are deposited in various places including kidney Most common site of deposition is in the subendothelial space of the glomerular basement membrane Can also be in the Bowerman's space, Basement membrane, and in Mesangial cells.

Answer 149

Depends on where the deposits are. This will determine the problems it causes the kidney - Can be either Nephrotic or Nephritic

Answer 150

Haematuria Proteinuria Hypertension Oedema Lethargy Musculoskeletal pain and butterfly rash

Answer 151

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

Answer 152

- **Renal biopsy: gold-standard** investigation. - **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 153

Anti dsDNA, antinuclear (ANA) and anti-smith

Answer 154

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

Answer 155

n Goodpasture syndrome, autoantibodies bind to a specific part of **the α3 chain that is usually hidden deep** within the folded triple helix of **Type IV collagen.** (makes the basement membrane if you can remember phase 1) This is a type II hypersensitivity reaction - autoantibodies, usually IgG but rarely IgM or IgA, bind to the the α3 chain, and activate the complement system

Answer 156

C1 is now activated, starts engages C2 through C9. The activated (cleaved) fragments C3a, C4a, and C5a act as chemotactic agents and attract other cells e.g. neutrophils. These cells cause the formation and release of free oxygen radicals Leads to damage the basement membrane as well as the nearby endothelium and the underlying organ itself.

Answer 157

Genetic factors such as HLA-DR15, and HLA-DRB1 or DR4 play a role as well as environmental factors **e.g. smoking, infection, oxidative stress, hydrocarbon based solvents that can damage the collagen molecules and expose the α3 chain to antibodies.**

Answer 158

This especially affects the kidneys and lungs as the kidney is responsible for filtering out toxins and so can be exposed to these environmental risks, and the lungs are exposed to the external environment. **Basically the lungs and Kidneys are more exposed to toxins that can damage the collagen, exposing the a3 chain to antibodies**

Answer 159

Reduced urine output Haemoptysis (pulmonary haemorrhage) Oedema

Answer 160

**Lung symptoms usually present before kidney symptoms** - Constitutional symptoms - **Lethargy** - **Fever** - **Anorexia** - **Weight loss** - **Myalgia**

Answer 161

**Lung symptoms usually present before kidney symptoms** Lungs - **Cough** - **Shortness of breath** - **Haemoptysis** - **Pulmonary haemorrhage:** may be seen on imaging - Kidneys - **Haematuria** - **Proteinuria** - **Oliguria/ anuria** - **Hypertension**

Answer 162

Renal function tests GOLD STANDARD- renal biopsy - show inflammation of basement membrane as well as lining up of antibodies against BM if fluorescent proteins are used **anti-glomerular basement membrane (anti-GBM) antibody titre** ANCA test (50% of patients will have these antibodies as well)

Answer 163

Oral corticosteroid Plasmapheresis to remove the anti-GBM antibodies Cyclophosphamide - a type of immunosupressant Dialysis may be required **One and done kind of disease**

Answer 164

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 165

**Proteinuria (>3.5g/day)** – damaged glomerulus more permeable 🡪 more protein come across from blood into nephron 🡪 proteinuria *(or nowadays look protein creatine ratio)* **Hypoalbuminaemia** – albumin leaves blood **Oedema (periorbital and arms)** – oncotic pressure falls due to less protein in blood 🡪 lower osmotic pressure 🡪 water driven out of vessels into tissues

Answer 166

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 167

Primary nephrotic - due to direct sclerosis of podocytes on the glomerulus * Minimal change disease * Focal segmental glomerulosclerosis * Membranous nephropathy Secondary Nephrotic Diabetes Amyloidosis

Answer 168

Normally, podocytes wrap around the glomerular capillaries and maintain the filtration barrier - preventing large molecular weight proteins from entering the urine, by ***ACTING AS A CHARGE BARRIER***

Answer 169

caused by T-cells in the blood, that **release cytokines-glomerular-permeability factor**, that specifically damages the foot processes of the podocytes, **making them flatten out - a process called effacement.** Damaged foot processes **lose their negatively charged coat, eventually allowing negatively charged molecules**, **MOST COMMONLY SEEN IN CHILDREN**

Answer 170

- allowing negatively charged molecules, like albumin, to slip into the nephron. - Even though albumin goes through, ***other larger proteins like immunoglobulins*** don't. - **So there's selective proteinuria;** in contrast to other causes of nephrotic syndrome which are characterised by **non-selective proteinuria.**

Answer 171

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 172

- On light microscopy, the glomeruli look completely normal. - In some cases, there can be lipids in the proximal tubular cells. - Immunofluorescence is negative. - The only changes are seen on electron microscopy, **where there’s effacement of podocyte foot processes.**

Answer 173

Management – corticosteroids ± cyclophosphamide or cyclosporine (for frequent relapsing cases) Normally respond very well to steroids.

Answer 174

Thickening of glomerular capillary wall. IgG, complement deposit in sub epithelial surface causing leaky glomerulus.

Answer 175

One major antigen that’s been identified is the **phospholipase A2 receptor or PLA2R** Therefore, **in patients in which MN is suspected, can do a** ***serum IgG PLA2R antibody test*** in order to test for MN

Answer 176

light microscopy, = Thickened GMB, due to IgG complex deposition On electron microscopy, there’s flattening of the podocyte foot processes and **subpodocyte/subepithelial deposits of immune complexes** See **Spike and Dome** pattern

Answer 177

Poor response to corticosteroids and individuals may progress to CKD

Answer 178

a disease in which scar tissue develops in sections of the glomeruli, the small parts of the kidneys that filter waste from the blood. its name describes how nephrons with this disease appear histologically.

Answer 179

a) Primary is idiopathic b) Secondary is down to other conditions, history of heroin abuse, HIV infection, Sickle Cell Anaemia

Answer 180

Light microscopy - SEGMENTAL SCLEROSIS AND HYALINOSIS OF THE GLOMERULUS Would see effacement of foot processes under electron microscope

Answer 181

* Membranoproliferative glomerulonephritis - *aka SLE nephritis* * Diffuse proliferative glomerulonephritis - *the one with 3 types, Hep B and C related, proliferation of mesangium - see tram track splitting of BM*

Answer 182

There are 3 types, 1 is most common subtype. they all cause **proliferation of mesangial and endothelial cells** in the glomerulus.

Answer 183

Through type III hypersensitivity reaction where there are circulating **immune complexes, from hep B or hep C infections**, activates compliment pathway leads to immune complexes and/or complement deposits end up in the subendothelium Lead to Thickening of basement membrane, triggers mesangial cells to proliferate and reach through basement membrane with cytoplasmic arms - **MESANGIAL INTERPOSTION**

Answer 184

“tram-track” appearance on light microscopy - due to mesangial interposition which sometimes causes the basement membrane to split around the mesangial cell, forming a duplication of the basement membrane

Answer 185

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

Answer 186

The prostate is a small gland that sits under the bladder and in front of the rectum. The urethra which is the tube through which urine leaves the bladder, goes through the prostate before reaching the penis. This part of the urethra is called the prostatic urethra.

Answer 187

- **The peripheral zone:** the outermost posterior section, is the largest of the zone and contain about 70% of the prostate’s glandular tissue. - **Central zone:** contains about 25% of the glandular tissue as well as the ejaculatory ducts that join with the prostatic urethra. - **Transitional zone:** contains around 5% of the glandular tissue as well as a portion of the prostatic urethra.

Answer 188

They secrete substances into the **prostatic fluid,** that make it alkaline ot help sperm survive in acidic pH of vagina, as well as nutrients for sperm The luminal cells also produce **prostate specific antigen, or PSA,** which helps to **liquefy the gel-like semen after ejaculation,** thereby freeing the sperm to swim.

Answer 189

rely on stimulation from androgens for survival. This includes **testosterone,** which is produced by the testicles, and **dihydrotestosterone,** which is produced in the prostate itself.

Answer 190

DHT is produced by **5α-reductase** in the prostate which converts testosterone into the more potent dihydrotestosterone. both **DHT and Testosterone bind to androgen receptors in the cell and prevent apoptosis allowing the prostate to continue to grow.** ***DHT is 10x more potent that Testosterone***

Answer 191

With age the levels of testosterone **drop but the levels of DHT increase as 5α-reductase activity increases**. The entire prostate gland enlarges uniformly and small hyperplastic nodules can form within it. Typically, hyperplastic nodules will form in the inner portions of the gland, **specifically around the prostatic urethra, called the periurethral zone.**

Answer 192

These nodules will compress the urethra making it more difficult to pass urine ==> **smooth muscles of the bladder will have to work harder** leading to bladder hypertrophy The stagnation of the urine in the bladder also promotes bacterial growth leading to UTIs So see **Dribbling Straining when urinating Painful urination (Dysuria) Trouble initiating urination (Hesitancy) Incomplete urination and more urination at night (Nocturia)**

Answer 193

Digital rectal examination findings - **Smooth, enlarged, and non-tender** **Lower abdominal tenderness and palpable bladder** - Indicates acute urinary retention - Perform bladder scan - Requires urgent catheterisation

Answer 194

In BPH, the enlargement feels **smooth and firm** while in prostate cancer, the gland may feel **hard and lumpy** - Enlarged in Both though

Answer 195

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 Transrectal ultrasound: can estimate prostate size and weight

Answer 196

α-1 antagonists: **Tamsulosin** it is considered first-line. It inhibits the action of noradrenaline and relaxes the smooth muscle. 5-α reductase inhibitors e.g. finasteride. This will work to reduce the prostate size but can take up to 6 months to work.

Answer 197

α-1 antagonists: eg tamulosin - Postural hypotension, dizziness, dry mouth and depression 5-α reductase inhibitors eg Finasteride - reduced libido, erectile dysfunction, and gynaecomastia

Answer 198

**Prostate <30 g**: - **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)

Answer 199

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

Answer 200

Prostate adenocarcinoma - ***ARISE IN THE PERIPHERAL ZONE***

Answer 201

transitional cell carcinoma arising from cells in the transitional zone, and small cell prostate cancer arising from neuroendocrine cells.

Answer 202

- Prostate cancer is the most common cancer in males in the UK - It is associated with an 84% overall survival rate - Common in Afro-Caribbean

Answer 203

- **Increasing age:** highest rates amongst men aged 75 to 79 years - **Family history**: 5-10% have a strong family history - **Afro-Caribbean ethnicity** - **Being tall** - **Obesity and high-fat diet** - **Use of anabolic steroids** - **Cadmium exposure:** found in cigarettes, batteries and those working in the welding industry Certain genes

Answer 204

BRCA1 and BRCA2 have been linked to prostate cancer

Answer 205

They most often results from a **genetic mutation in a luminal cell,** but can also be a basal cell, and it results in that cell dividing uncontrollably forming a tumour. Early on, prostate cancer cells depend heavily on androgens for survival, but eventually, the **cancer cells mutate and find a way to keep multiplying without relying on androgens.**

Answer 206

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

Answer 207

**On DRE**Asymmetrical, hard and nodular prostate with the loss of the median sulcus Urinary retention Palpable lymphadenopathy: indicates metastatic disease

Answer 208

***Early prostate cancers may not cause symptoms as they usually start in posterior area*** - **Frequency** - **Hesitancy** - **Terminal dribbling** - **Nocturia** - **Haematuria or haematospermia** - **Dysuria** - **Constitutional symptoms: e.g. weight loss, fatigue** - **Bone pain**: e.g. lumbar back pain: suggests metastatic disease

Answer 209

Prostate-specific antigen (PSA) **Multiparametric MRI is now first-line** Previously, **transrectal ultrasound (TRUS)-guided needle biopsy** was the gold-standard diagnostic investigation

Answer 210

***Gleason score*** From biopsy - assigned a score on a scale of 3 to 5 from 2 different locations. Cancer cells that look similar to healthy cells receive a low score. Cancer cells that look less like healthy cells or look more aggressive receive a higher score.

Answer 211

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 212

Active surveillance or observation

Answer 213

**External beam radiotherapy** directed at the prostate Brachytherapy ***placing radioactive seeds into the prostate to continuously deliver radiotherapy*** Hormone therapy - **anti-androgen eg Flutaminde**

Answer 214

**Radical prostatectomy** Removal of the prostate, seminal vesicles, ampulla, and vas deferens, **+/- pelvic lymph node dissection;** often performed robotically **Option 4: Docetaxel chemotherapy with anti-androgen therapy** - Chemotherapy must not be used alone - Also used to treat metastatic cancer - Docetaxel is an anti-microtubule agent that block cell proliferation

Answer 215

- Metastatic cancer - Treated with docetaxel chemotherapy **and** **anti-androgen therapy** - **Bilateral orchidectomy (removal of testes to cause androgen deprivation)** should be offered as an alternative to LHRH agonists

Answer 216

**Cancer-related:** - **Urinary retention** - **Metastasis:** most commonly to bone **Procedure or treatment-related:** - **TRUS biopsy**: haematuria and rectal bleeding, pain, sepsis (1%) - **Surgery:** urinary incontinence, erectile dysfunction (common) - **Radiotherapy**: proctitis, cystitis, colorectal cancer, bladder cancer - **Hormone therapy**: gynaecomastia, hot flushes - **Surgery, radiotherapy or hormones**: erectile dysfunction

Answer 217

benign prostatic hyperplasia or BPH inflamed or infected prostate (prostatitis). Digital rectal examination. High levels of physical activity. Ejaculation. Also, PSA levels normally increase with age ***Obesity has been shown to actually lower PSA levels from the expected ranges in some cases***

Answer 218

Germ Cells - differentiate into spermatogonia Sertoli Cells - provide nutrients to developing sperm

Answer 219

Leydig cells - secrete testosterone, that is allowed into the tubule lumen by Sertoli cells, **essential for sperm development** Blood Capillaries are outside

Answer 220

Germ cell tumours there are 5 types of this

Answer 221

Non-germ cell (sex-cord stromal) cancer of either Leydig or Sertoli cells - **Leydig cell tumours:** - will lead to excess Testosterone secretion = causes premature puberty. OR, can have Excess oestrogen can cause delayed puberty and feminisation - **Sertoli cell tumour:** usually clinically silent and benign

Answer 222

- **Young males:** seminoma > 35 years; non-seminoma < 35 years - **Caucasian** - **Family history** - **Infertility**: 3-fold increased risk - **Cryptorchidism:** highest risk in abdominal and bilateral undescended testes - **Intersex conditions**: e.g. Klinefelter’s syndrome (extra X chromosome = small undeveloped testicles) - **In-utero exposure to pesticides or synthetic sex hormones** - **Mumps orchitis:** pain and swelling in testicles after mumps - **Testicular atrophy:** often following trauma

Answer 223

- **Seminoma:** most common and best prognosis. Made of germ cells that multiply without differentiation **SECRETE PLACENTAL ALKALINE PHOSPHATASE (PLAP) - normally secreted by the placenta**

Answer 224

Embryonal carcinoma: aggressive and metastasises early. - **embryonic pluripotent stem cells ** Teratoma: composed of tissue from **different germinal layers e.g. teeth, any type of tissue** Yolk-sac tumour: common in children and aggressive. - **made from yolk sac tissue** Choriocarcinoma: rare but most aggressive. Made out of germ cells that **differentiate into syncytiotrophoblasts and cytotrophoblasts** (cells that help form placenta)

Answer 225

- **Firm non-tender testicular mass** - Does not transilluminate - Hydrocele (swelling in scrotum) may be present - **Supraclavicular lymphadenopathy**

Answer 226

Acutely painful scrotum - **testicular torsion until proven otherwise** Epidiymo-orchitits Hydrocele Varicocele Epidydimal Cyst

Answer 227

- **Painless testicular lump** - **Sometimes sharp or dull testicular pain and lower abdominal pain** - 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** - **Bone pain:** indicates skeletal metastasis - **Breathlessness, cough or haemoptysis:** indicates lung metastasis - **Back pain:** indicative of lymph node metastasis

Answer 228

**Gold standard - Doppler Ultrasound of testicles** Tumour markers: β-hCG, AFP (alpha-fetoprotein), and LDH (Lactate dehydrogenase) must be measured prior to surgery. ***DO NOT DO BIOPSY, CAN PROVIDE AN EXTRA ROUTE FOR POTENTIAL METASTITSES***

Answer 229

- **Radical orchiectomy** - **Post-orchiectomy active surveillance**: for patients with low-risk disease Post-orchiectomy radiotherapy or chemotherapy: radiotherapy is offered in locally-invasive disease, however, carboplatin (chemo) can be used as an alternative

Answer 230

- **Increasing age**: most common in patients aged 50 to 80 years old - **Male** - **Family history** - **Alcohol** - **Extended dwell times**: not emptying bladder for long periods of time **aromatic hydrocarbons** Drugs - Cyclophosphamide: medication used to treat cancers and autoimmune diseases Painters and hairdressers, roofer have occupational risk

Answer 231

- **Urothelial** (most common >90%) - **Non-urothelial** - Squamous cell carcinoma (1-7%) - Adenocarcinoma (2%) - Sarcoma - Small cell

Answer 232

Schistosomiasis - an acute and chronic parasitic disease caused by blood flukes (trematode worms)

Answer 233

Over 45 with unexplained haematuria Over 60 with microscopic haematuria on urine dipstick plus dysuria or raised WCC The NICE guidelines also recommend considering a non-urgent referral in people over 60 with recurrent unexplained UTIs.

Answer 234

haematuria LUTs Recurrent UTIs Dysuria (pain when urinating) can occur Palpable suprapubic mass in advanced cases

Answer 235

- **Urinalysis:** haematuria - **Bloods:** - **FBC:** assess Hb in patients with chronic haematuria Flexible cystoscopy and biopsy: under local anaesthetic to confirm the presence of a bladder tumour; gold-standard diagnostic investigation

Answer 236

**Trans-urethral resection of bladder tumour (TURBT):** rigid cystoscopy under general anaesthetic, with a post-operative dose of **intravesical mitomycin C (chemotherapy).** - **Intermediate risk:** 6 doses of intravesical mitomycin C - **High risk:** intravesical **BCG vaccine**

Answer 237

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 238

- **Radical cystectomy** with neoadjuvant chemotherapy; patients will require an ileal conduit (urostomy) -*removal of whole bladder, nearby lymph nodes as well as prostate, seminal vesicles/womb, fallopian tubes* - **Radical radiotherapy** with neoadjuvant chemotherapy is an alternative to surgery

Answer 239

- **Increasing age**: peak age between 60 and 70 years of age - **Male**: 3:2 ratio of men to women - **Black ethnicity** - **Hereditary** e.g. Von Hippel-Lindau, Hereditary papillary RCC, Birt Hogg Dube - **Smoking** - **Obesity** - **Hypertension** - **Haemodialysis** **Smoking, and Von Hippel-Lindau are biggest risk factors**

Answer 240

Renal cell carcinoma (RCC) is an **adenocarcinoma** most commonly arising from the epithelium of the **proximal convoluted tubule.** It is also known as hypernephroma or Grawitz tumour, OR **CLEAR CELL CARCINOMA**

Answer 241

Classic triad: haematuria, flank pain, abdominal mass (seen in 10-15% of patients) Constitutional symptoms: e.g. weight loss, fatigue, fever of unknown origin bilateral ankle oedema, If there are metastases then **haemoptysis, bone pain or pathological fracture can all be seen.** **50% OF RCC ARE PICKED UP INCIDENTALLY ON A SCAN FOR SOMETHING ELSE**

Answer 242

Hypertension - **DUE TO INCREASED RENIN SECRETION** Flank mass Left sided varicocele

Answer 243

Abdominal ultrasound: a sensitive initial modality to help identify benign vs. malignant lesions but CT/MRI is needed if RCC is suspected

Answer 244

CT abdomen/pelvis with contrast: the definitive test for diagnosis, with 90% sensitivity and 100% specificity in identifying malignancy

Answer 245

Sunitinib and pazopanib which are tyrosine kinase inhibitors

Answer 246

Overall 5-year survival is near 70%, whilst early-stage disease has an excellent 5-year survival of >90%. Survival from metastatic disease has almost doubled since the introduction of Sunitinib, with an overall 5-year survival between 30 and 50% in patients with pulmonary metastasis

Answer 247

Wilms’ tumour is a specific type of tumour affecting the kidney in children, typically under the age of 5 years. It is the chief abdominal malignancy in children

Answer 248

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 249

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 250

code for the polycystin 1 and polycystin 2 proteins - **components of primary Cilium** The primary cilium is an appendage that sticks out from most cells in the body and receives developmentally important signals. - seen all over the body

Answer 251

In the nephron, as the urinary filtrate flows by and cause the cilium to bend, polycystin 1 and polycystin 2 respond by allowing calcium influx, which activates pathways in the cell that inhibit cell proliferation.

Answer 252

If either PC1 or PC2 gene is absent, no signal that inhibits growth - so cells proliferate abnormally and **start to express proteins that cause water to be transported into the lumen of the cyst,** which makes them get larger and larger, compressing the surrounding tissue more and more. This is how cysts develop and grow

Answer 253

A person who develops ADPKD would have **1 single, heterozygous mutation in PKD1 or PKD2** and one functional copy of the gene = this one copy and this produces enough polycystin 1 or polycystin 2 to prevent cyst formation. BUT a **random mutation in the remaining good copy of the gene is almost guaranteed to happen** in some of the tubular cells as the kidney develops. This ‘second hit’ causes polycystin 1 or 2 to be absent and is what impairs normal signalling through the cilium and leads to cyst formation.

Answer 254

when someone inherits a mutation on **both copies of the PKHD1 gene, which codes for the fibrocystin protein.** Means that cyst formation will lead to renal failure even before birth - no urine produced, and since amniotic fluid comes from foetal urine, **- there is no amniotic fluid**

Answer 255

can cause **Potter syndrome:** without the amniotic fluid, the uterine walls compress the foetus. Causes physical developmental abnormalities, like **club feet, underdeveloped ear cartilage, low set ears, a flat nasal bridge and abnormalities of the skeleton congenital portal hypertension**

Answer 256

- **Bilateral flank masses**: due to large polycystic kidneys - **Hypertension**: seen in most patients by 4th decade of life

Answer 257

- **Abdominal, flank or back pain**: due to large size or cyst complications (rupture/infection) - **Haematuria**: typically occurs in association with ruptured cyst - **Dysuria and fever**: suggestive of urinary tract infection or infected cyst - **Renal colic**: nephrolithiasis (i.e. stones) more common - **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 258

- **Polycystic liver disease**: seen in > 80% of patients on MRI imaging. - **Hepatomegaly**: if polycystic liver disease - **Pancreatic cysts**: seen in up to 36% of patients. - **Cerebral aneurysms**: four times higher compared to general population. Rupture most serious complication of ADPKD. - **Cardiac valve disease**: seen in 25-30%. Most commonly mitral valve prolapse and aortic regurgitation. - **Gastrointestinal abnormalities**: diverticulosis and hernias (abdominal/inguinal) occur at higher frequency - **Seminal vesicle cysts and infertility**

Answer 259

- **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) - **CT KUB**: if presenting with suspected renal stone - **Cerebral imaging (e.g. MRA)**: screening for cerebral aneurysm *MRA - Magnetic resonance angiography–also called a magnetic resonance angiogram or MRA–is a type of MRI that looks specifically at the body's blood vessels*

Answer 260

- **General treatment:** - Blood pressure control: ACE inhibitors - Regular follow-up including renal function assessment and ultrasound to look for progression Maintain adequate hydration Treatment for high-risk patients: **vasopressin (V2) receptor antagonists e.g. Tolvaptan** Transplant/ dialysis: in cases of kidney failure

Answer 261

Chlamydia trachomatis A gram-negative bacteria. It is an intracellular organism, meaning it enters and replicates within cells before rupturing the cell and spreading to others. More common in female

Answer 262

Abnormal vaginal discharge Pelvic pain Abnormal vaginal bleeding (intermenstrual or postcoital) Painful sex (dyspareunia) Painful urination (dysuria) **Asymptomatic** in 50% of cases

Answer 263

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

Answer 264

7-21 days b) 2-5 days

Answer 265

Adult – both infect non-squamous epithelia Urethra Endocervical canal Rectum Pharynx Conjuctiva

Answer 266

Conjuctiva Atypical pneumonia also in neonatal chlamydia

Answer 267

Urethral discharge or discomfort Painful urination (dysuria) Epididymo-orchitis Reactive arthritis **Asymptomatic** in 50% of cases

Answer 268

Chlamydial Conjunctivitis

Answer 269

100mg of doxycycline twice a day for 7 days

Answer 270

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

Answer 271

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

Answer 272

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 273

Near patient test Microscopy of gram stained smears of genital secretions looking for gram negative diplococci within cytoplasm of polymorphs Culture on **Gonococcus agar** Male - urethra Female - endocervix Rectum

Answer 274

Nucleic Acid Amplification Tests (NAAT) High specificity and sensitivity Female Self-collected vaginal swab Endocervical swab Male – first void urine

Answer 275

Syphilis is caused by bacteria called Treponema pallidum. This bacteria is a spirochete, a type of spiral-shaped bacteria.

Answer 276

The bacteria gets in through skin or mucous membranes, replicates and then disseminates throughout the body. It is mainly a sexually transmitted infection. The incubation period between the initial infection and symptoms is 21 days on average.

Answer 277

Primary syphilis **involves a painless ulcer called a chancre at the original site of infection** Secondary syphilis Latent syphilis *symptoms disappear and the patient becomes asymptomatic despite still being infected.* Tertiary syphilis Neurosyphilis occurs if the infection involves the central nervous system

Answer 278

A painless genital ulcer (chancre). This tends to resolve over 3 – 8 weeks. Local lymphadenopathy

Answer 279

ypically 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 280

Tertiary syphilis can present with several symptoms depending on the affected organs. Key features to be aware of are: Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones) Aortic aneurysms Neurosyphilis

Answer 281

Antibody testing for antibodies to the T. pallidum bacteria can be used as a screening test or Samples from sites of infection can be tested to confirm the presence of T. pallidum with: Dark field microscopy Polymerase chain reaction (PCR)

Answer 282

. As with all sexually transmitted infections, patients need: Full screening for other STIs Advice about avoiding sexual activity until treated Contact tracing Prevention of future infections A single deep **intramuscular dose of benzathine benzylpenicillin (penicillin)** is the standard treatment for syphilis.

Answer 283

The epididymiis a tube that connects a testicle to a vas deferens in the male reproductive system. It is a single, narrow, tightly coiled tube in adult humans, 6-7m long It serves as an interconnection between the multiple efferent ducts at the rear of a testicle (proximally), and the vas deferens (distally).

Answer 284

1. *Can you get above it?* 2. *Is it separate from the testis?* 3. *Cystic or solid?*

Answer 285

General Rule of Thumb Testicular lump – cancer until proven otherwise Acute and tender lump – torsion until proven otherwise

Answer 286

- Separate and cystic = epididymal cyst - Separate and solid = epididymitis, varicocele

Answer 287

- Testicular and cystic = hydrocele - Testicular and solid = tumour, haematocele, granuloma, orchitis, gumma (non cancerous growth)

Answer 288

Abnormal dilation of testicular veins in the pampiniform venomous plexus, caused by venous reflux

Answer 289

Left side more commonly affected Unusual in boys under 10 Incidence increases after puberty Associated with sub-fertility

Answer 290

Angle at which the left testicular vein enters the left renal vein Increased reflux from compression of renal vein Lack of effective valves between the testicular and renal veins

Answer 291

The pampiniform plexus drains via the **gonadal (testicular) veins.** Anything that leads to increased pressure may cause varicoceles. Impaired venous drainage 🡪 increased venous pressure 🡪 vein dilatation The left gonadal vein is longer and joins the left renal vein at a right angle, which impair venous drainage, compared to the **right gonadal vein that drains more obliquely,** directly into the IVC.

Answer 292

- **Palpable veins (described as bag of worms)** - **Scrotum may hang lower on side of varicocele** - **Signs of testicular atrophy may be seen on the affected side.** - Symptoms - **Painless testicular swelling** - May reduce on lying and be exacerbated by a Valsalva manoeuvre (slow breathing)

Answer 293

What are the investigations for a varicocele? Testicular examination: demonstrates dilated veins (bag of worms) - 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 294

- **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 295

**Refer any patient who’s varicocele becomes symptomatic.** Urgent referral is advised if: - **It appears suddenly and is painful** - **Does not drain when lying down** - **Solitary right-sided varicocele** Adolescents may be referred if: - **Reduced testicular volume** - **Patient or parental concern**

Answer 296

Varicoceles that do not disappear when lying down raise concerns about **retroperitoneal tumours obstructing the drainage of the renal vein.** These warrant an urgent referral to urology for further investigation.

Answer 297

- Surgical - **Inguinal / subinguinal approach** - **Retroperitoneal high ligation** - Endovascular - **Antegrade sclerotherapy** *Sclerotherapy involves using a needle to put a solution into the vein. The sclerotherapy solution causes the vein to scar. The scarring forces blood through healthier veins. The collapsed vein then fades.*

Answer 298

Testicular torsion refers to twisting of the spermatic cord with rotation of the testicle. leading to ischaemia and eventually necrosis. **“6 hour window” after onset before damage from ischaemia is irreversible!**

Answer 299

- Quite common in adolescent boys and young men - Two peaks; one in the neonatal period and one around puberty, with a peak incidence of 13 to 15 years old Often triggered by playing sport - **ask about this in onset of symptoms**

Answer 300

- **Young age** - **Bell clapper deformity:** high riding testicle with a horizontal lie - - **Cryptorchidism:** undescended testis increase the risk of torsion and would usually present in the first few months of life - **Trauma:** trauma-induced torsion accounts for less than 10% of cases

Answer 301

Normally the testicle is **fixed posteriorly to the tunica vaginalis.** Bell-clapper deformity is where this fixation is absent. It allows testicle to rotate within tunica and as it rotates it twists the vessels and cuts of its blood supply

Answer 302

- **Swollen, high-riding and tender testicle: skin may be erythematous** - **Abnormal lie** - Horizontal lie - Rotated so that epididymis is not in normal posterior position - Elevated (retracted) testicle **absent cremasteric reflex, and prehns sign negative** *(Prehns is positive in epididymtis)*

Answer 303

- **Absent cremasteric reflex** - Swipe the superior and inner part of the thigh - A normal reflex contracts the cremaster muscle, pulling up the ipsilateral testis Reflex almost always absent - **Prehn’s negative:** - Pain is **not** relieved on lifting the ipsilateral testicle, unlike in epididymitis

Answer 304

- **Testicular pain** - Usually unilateral, sudden onset and excruciatingly painful - Often triggered by activity - Pain may be severe, intermittent and self-limiting; intermittent pain does **not** rule out torsion - **Nausea and vomiting** secondary to pain is common - **Lower abdominal pain:** referred pain - ***ADBO PAIN MAY BE THE ONLY SYMPTOM, SO ALWAYS DO TESTICULAR EXAM ON A LAD WITH UNEXPLAINED ABDO PAIN***

Answer 305

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. Can do Testicular ultrasound: operator-dependent; ‘whirl-pool’ sign suggests torsion, as does decreased blood flow in the affected testicle on colour doppler **HAVE TO OPERATE WITHIN 6 HOURS OF SYMPTOM ONSET TO PREVENT NECROSIS**

Answer 306

- **Viable testicle** **Bilateral orchiopexy:** the affected testicle is untwisted and fixed to the scrotal sac. The contralateral testicle should always be fixed to prevent contralateral torsion - **Non-viable testicle** **Ipsilateral orchiectomy and contralateral orchiopexy:** removal of the affected testis and fixation of the contralateral testis to the scrotal sac to prevent contralateral torsion **HAVE TO OPERATE WITHIN 6 HOURS OF SYMPTOM ONSET TO PREVENT NECROSIS**

Answer 307

Torsion of the appendix testis is a **twisting of a vestigial appendage that is located along the testicle.** This appendage has no function, yet more than half of all boys are born with one. It is also known as **Hydatid of Morgagni (embryonic remnant of the Mullerian duct)** Although this condition poses no threat to health, it can be painful. Usually no treatment other than to manage pain is needed.

Answer 308

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

Answer 309

Simple - overproduction of fluid in the tunica vaginalis Communicating - processus vaginalis fails to close, allowing peritoneal fluid to communicate freely with the scrotal portion

Answer 310

Investigations Scrotal ultrasound Serum AFP and HCG to help exclude malignant teratomas or other germ cell tumours

Answer 311

Management Resolve spontaneously Many of infancy resolve by 2 years **Therapeutic aspiration** or surgical removal

Answer 312

Smooth, extra-testicular, spherical sac of fluid in the head of the epididymis (top of testicle). - also known as a *spermatocele*

Answer 313

- Signs - **Palpable lump** (often multiple and bilateral) - **Well defined** and will **transluminate** since fluid-filled - Symptoms - Can cause **dragging and soreness** - May be **pain** if cysts are large

Answer 314

- Investigations - **Scrotal ultrasound** - Differential diagnosis - **Hydrocele** - **Varicocele** - Management - **Usually not necessary** - **Removed, if symptomatic**

Answer 315

When bladder half full, **stimulates stretch receptors in bladder wall** ===> Send impulses to the sacral spinal chord, at levels S2 and S3 - PELVIC SHPLANIC NERVE, these signals then go up to micturition centre in the pons

Answer 316

**Micturition reflex** Activation of pelvic splanchnic nerve S2-S4 cause the detrusor muscles to CONTRACT - *at sacral micturition centre,* ***Onuf's Nucleus*** - When the detrusor muscle contract, the change in bladder shape pulls open the internal urethral sphincter - is **made of smooth muscle** **Micturition reflex** also decreases motor nerve stimulation to the external sphincter allowing it to relax as well. At this point, urination should occur, but why don't just wet ourselves every time the bladder is half full?

Answer 317

At this point we should just wee ourselves every time the bladder is half full, however at this point, the **PONTINE STORAGE CENTRE OVERIDES MICURITION RELFEX** It does this by activating SYMPATHETIC, **HYPOGASTIRC NERVES T10 - L2**, that cause DETROUSER RELAXATION, and BLADDER NECK CONTRACTION

Answer 318

Responsible for giving the **sensation of a full bladder** **initiates the act of voiding bladder**

Answer 319

- Urge incontinence: - Stress incontinence - Mixed incontinence: Overflow incontinence (neurogenic bladder):

Answer 320

- **Diabetes** - **Bladder cancer** - **Parkinson's** - **Multiple sclerosis** - **Prostatectomy** - **Hysterectomy**

Answer 321

Sudden urge to urinate because of an "overactive bladder", followed immediately by involuntary urination typically due to an uninhibited detrusor muscle that contracts randomly. Usually associated with urinary tract infections. Inflammation may trigger the detrusor muscle.

Answer 322

Increased abdominal pressure overwhelms the sphincter muscles and allows urine to leak out. Causes include pregnancy and exertion, like sneezing, coughing, laughing.

Answer 323

Due to either - Obstruction due to blockage in urine flow or Ineffective detrusor muscle. ==> **Detrusor cant contract properly so the bladder doesn’t empty** properly In both cases, **leads to urine build up, to the point that the bladder is so full that urine dribbles/leaks** out through sphincters Obstruction - - eg benign prostatic hyperplasia, Ineffective detrusor = Diabetes (neurogenic bladder) Multiple sclerosis, Spinal chord injury

Answer 324

- Urge incontinence: **frequent urination, especially at night** - Stress incontinence: **urinary leakage with pressure applied to the abdomen** - Overflow incontinence: **weak or intermittent stream or hesitancy**

Answer 325

Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line - **Anticholinergic medication**, for example, oxybutynin, tolterodine and solifenacin - **B3 adrenergic agonist: mirabegron**

Answer 326

- **Avoiding caffeine, diuretics and overfilling of the bladder** - **Avoid excessive or restricted fluid intake** - **Weight loss** (if appropriate) - **Supervised pelvic floor exercises** for at least three months before considering surgery - **Pessary** - *It is a firm ring that presses against the wall of the vagina and urethra to help decrease urine leakage.*

Answer 327

Re-establish a clear pathway for urine flow e.g. catheterisation or medications like **alpha-blockers, which relax smooth muscle** to assist with urination.

Answer 328

Liver cirrhosis leads to portal hypertension In response to this, **portal blood vessels dilate,** stretched by large amounts of blood pooling there. This leads to a loss of blood volume elsewhere, including kidneys. Leads to **hypotension in the kidney and activation of the RAAS.** This causes renal vasoconstriction, which combined with low circulation volume leads to starvation of blood to the kidney *Hepatorenal syndrome is fatal within a week or so unless liver transplant is performed.*

Answer 329

- **Swollen ankles/ oedema** - **Increased bleeding:** excess urea in the blood makes platelets less likely to stick to each other Bone disease – osteomalacia, osteoporosis - ***Less 1, 25-dihydroxyvitamin D from kidneys = less Serum calcium - more PTH and bone remodelling** Lethargy - due to anaemia

Answer 330

Three thiazide diuretics are the most commonly used: hydrochlorothiazide (HCTZ), chlorthalidone, and indapamide treat hypertension, reduce risk of kidney stones

Answer 331

1 >90 Normal or increased GFR with *other evidence of renal damage* 2 60–89 Slight decrease GFR with *other evidence of renal damage* 3 A - 45–59, 3 B - 30–44 = Moderate decreased GFR with or without evidence of other renal damage 4 15–29 Severe decreased GFR with or without evidence of renal damage 5 <15 Established renal failure GFR clock!!!

Answer 332

act at the ascending limb of the loop of Henle **Reversibly inhibit the Na/K/Cl cotransporter**, inhibiting the reabsorption of filtered sodium and chloride ions. Ergo hypertonicity of the renal medulla, thus inhibiting water reabsorption by the collecting ducts. eg Furosemide, Torsemide

Answer 333

Work on the distal convoluted tubule inhibit reabsorption of sodium and chloride ions, by **blocking the thiazide-sensitive Na-Cl symporter**. Inhibits the reabsorption of water, reabsorption of water is also inhibited, as water follows sodium. Examples include clorothiazide and Bendroflumethiazide.

Answer 334

binds competitively to the aldosterone receptor (AR) at the **aldosterone-dependent sodium-potassium exchange site.** This promotes sodium and water excretion and potassium retention

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