Renal & Genitourinary Flashcards
Sites of ureteric constriction (sites where urinary stones can lodge)
- Pelvicureteric junction
- Pelvic Brim
- Vesicoureteric junction
Anatomy of kidney
Structure of nephron
Pathophisiology of kidney stones (nephrolithiasis)
Within tubule of nephrons crystal like structures can form. These crystal like structures are precipitance of electrolytes that have acculumated. Urine supersaturation with stone forming salts -> crystal formation
If crystal is small it will pass in urine.
If crystal remains in kidney it becomes a stone
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Clinical presentation of kidney stones
Triad: fever, vomiting, flank pain
Risk Factors for developing kidney stones
What do the risk factors in developing kidney stones increase/decrease ?
Increase urinary solutes (Calcium, uric acid, oxalate and sodium)
Decrease stone inhibitors (citrate and magnesium)
=this causes urine supersaturation leading to urinary crystal formation
What factors contribute to urine supersaturation and therefore urinary crystal formation
Increase urinary solutes (calcium, uric acid, oxalate and sodium)
Decrease stone inhibitors (citrate and magnesium)
Dcerease urinary volume
Increase/decrease urinary pH
Stone pathology
Investigations for kidney/urinary stone formation
Acute management of kidney stones
Management of kidney stones
Percutaneous nephrostomy (symptomatic relief)
Ureteric stent insertion
Percutaneous nephrolithotomy
Endoscopic treatment/open surgery
Extracorporeal shock wave lithotripsy
What is acute kidney injury
sudden deterioration in kidney function
What is kidney fucntion measured in?
Glomelular Filtration Rate
What is GFR?
Flow rate of filtered fluid through the kidney
How is GFR measured?
Difficult to measure directly, estimated using creatinine clearance
Cockcroft-Gault formula:
Causes of Acute Kidney Injury
Signs and symptoms of acute kidney injury
Diagnosis of acute kidney injury
Definition:
1. Increase in serum creatinine of 26micromol/l in 48h
2. Increase in serum creatinine of 1.5x of baseline
3. Urine production below 0.5mol/kg/h
List some nephrotoxic medication (DAMN)
D:iuretics
A: CEi/ARB/antibiotics
M: etformin
N: SAIDs
Tretment for AKI
Indications for acute dialysis
What is chronic kidney disease
Progressive, irreversible condition characterised by reduced kidney function or kidney damage (Any cause), lasting for >=3 months
Classification of chronic kidney disease
Based on GFR
Symptoms and complication of chronic kidney disease
Aetiology of CKD
Most common causes:
1.Type 2 diabetes mellitus (30-50%)
Type 1 diabetes mellitus (4%)
- Hypertension
Pathophysiology of CKD
Epidemiology + Risk Factors for CKD
Diagnosis of CKD
Treatment for CKD
+Renal Replacement therapy:
Usually later stages but not based on GFR alone
Extracorporeal: haemodialysis/haemofiltration, peritoneal dialysis, renal replacement
What is a urinary tract infection
Bacterial infection of the urinary tract
Causative agents:
1. E-coli (80%)
2. Enterobacteriae
3. Proteus mirabilis
4. Klebsiella pneumoniae
Why are women at a greater risk of getting a UTI
Urethra is shorter than males
Lower Urinary Tract Infection
- Cystitis (bladder)
- Prostatitis (prostate)
- Urethritis (urethra)
- Epidydmo-Orchitis
Upper Urinary Tract Infection
Pyelonephritis (kidney)
Pathogenesis of UTI
- Contamination
- Colonisation in urethra/bladder
- Inflammatory response
- Neutrophil infiltration
- Bacteria multiply: Immune system evasion (virulence)
- Ascension to the kidney
- Colonisation of kidney
- Bacteremia
Risk Factors for UTI
Signs and symptoms of UTI
Classification of UTI
Investigations + Diagnosis for UTI
Treatment for UTI
Prevention of UTI
What is nephritic syndrome?
Collection of signs and symptoms as a result of glomerulonephritis
Nephritic syndrome vs nephrotic syndrome
Anatomy of Glomerulus
Pathophysiology of nephritic syndrome
Cause -> Inflammation: cell proliferation, complement, leukocyte recruitment, protease/free radials -> injury
Signs and symptoms of nephritic syndrome
Characteristics of nephritic syndrome:
1. Proteinuria
2. Haematuria: Acanthocyte
3. RBC casts: suggestive of GN
4. Sterile pyuria
5. RAAS activation -> Hypertension
6. Decrease GFR -> Oliguria
Causes of nephritic syndrome
- Rapidly progressive glomerulonephritis (RPGN) aka “crescentic GN”
a. Anti glomerular basement membrane (Goodpasture’s)
b. Immune complex mediated
-IgA neuropathy (Berger disease)
-Post Streptococcal Glomerulonephritis
-Diffuse proliferative glomerulonephritis
Anti glomerular basement membrane (Goodpasture’s)
IgA neuropathy (Berger disease)
Post Streptococcal Glomerulonephritis
Diagnosis of nephritic syndrome
Treatment for nephritic syndrome
SLE neuropathy (Lupus nephritis)
caused by lupus and can present as nephrotic and nephritic syndrome
occurs due to immune complexes in the nephron. It is a type III hypersensitivity.
inflammation can be detected by biopsy
Treatment is the same as lupus:
-corticosteroids
-mycophenolate
-cyclophosphamide
Pathophisiology of nephrotic syndrome
Injury to structures -> Excessive protein loss -> Hypoalbuminemia
Signs and symptoms of nephrotic syndrome
Causes of nephrotic syndrome
1.Minimal change disease
2.Focal segmental glomerulosclerosis
3.Membranous nephropathy
Can be primary (idiopathic) or secondary
Minimal change disease
95% cases in children
abnormalities seen on electron microscopy
mostly primary
secondary causes include: hodgkin’s lymphoma & NSAIDs
Focal segmental glomerulosclerosis
Primary possible
More commonly secondary: HIV, obesity, reflux nephropathy, drugs: lithium, biphosphanates
Genetic: Nephrin (slit diaphragm), laminin 2 (GBM)
Membranous nephropathy (membranoproliferative glomerulonephritis)
Thickening of basement membrane
Spike and dome pattern of immune deposits in the suepithelial space
70% primary, 1/3 secondary
Secondary causes: malignancy, hepatitis, syphilis, lupus, drugs (penicillamine, NSAIDs)
Epedimiology/Risk Factors of nephrotic syndrome
Diagnosis of nephrotic syndrome
Treatment for nephrotic syndrome
What is benign prostatic hyperplasia (BPH)
non-cancerous growth of the prostate gland
common in men over 50
not premalignant
characterised by nodular prostatic hyperplasia
Anatomy of the prostate
Anatomy of prostate gland
Symptoms of BPH
Diagnosis of BPH
Treatment for BPH
Causes of BPH
What is prostate cancer
prostate cancer is a tumor or growth that originates in the prostate gland
Types of prostate cancer
1.Prostate adenocarcinoma: arises from luminal/basal cells
2.Transitional cell cancer: arises from prostatic urethra thransitional epithelium cells
3.Small cell prostate cancer: arises from neuroendocrine cells
Prostate adenocarcinoma
most common type
genetic mutation in a luminal cell or basal cell
mutation in 2 genes (BRCA1 & BRCA2)
Risk Factors:
1. Old age
2. Obesity
3. High fat/low fiber diet
Symptoms of prostate cancer
early on there are no symptoms
if cancer does compress urethra or bladder:
difficulty urinating
bleeding
pain with urination and ejaculation
if metastatic, spreads to bones (e.g vertebrae or pelvis) -> hip/lower back pain
Diagnosis of prostate cancer
Digital rectal exam
Transrectal ultrasound or MRI
Prostate cancer can cause elevation in prostate specific antigen
=ULTIMATELY REQUIRES BIOPSY for GLEASON GRADING SYSTEM
What is the Gleason Grading system
Identifies 2 most common cell patterns for prostate cancer
Score (1-5)
Numbers added = total gleason score (2-10)
1: Normal (well differentiated)
5: Abnormal cells
Treatment for prostate cancer
Scrotal diseases:
Varicocele
Testicular torsion
Epididymal cyst
Hydrocele
What is a varicocele
testicular disorder of young adults characterised by dilatation of pampiniform venous plexus, internal spermatic vein
most common cause of scrotal enlargement in young adults
usually let sided (>80%) due to increase in flow of resistance from left testicular vein drainage into left renal vein; right testicular vein drains directly to inferior vena cava (decrease flow resistance)
Types of varicocele
Large: easily identified by inspection as distention
Moderate: identified by palpation as “bag of worms”
Small: identified only as bearing down -> Increase abdominal pressure -> impeding drainage -> Increase varicocele size
Causes of varicocele
Signs and symptoms of varicocele
throbbing/dull pain: worse on standing
dragging sensation
infertility
Diagnosis of varicocele
Doppler ultrasound
CT scan
Semen analysis
Treatment for varicocele
surgery
What is testicular torsion
Rotation of the testicle with strangulation of its blood supply
Emergency
Can lose testicle in 6 hours
Ages 12-18
Symptoms of testicular torsion
Severe local pain
Nausea/vomiting
Scrotal oedema
Testis may be horizontally elevated
Loss of cremasteric reflex: stroke inner thigh, pulls up testis
(-) Prehn’s sign: elevate testis, pain is NOT relieved in testicular torsion
Diagnosis of testicular torsion
Color doppler ultrasound
Contrast enhanced MRI
Treatment for testicular torsion
Manual detorsion
Surgical
Risk factor for testicular torsion
Bell Clapper deformity
What is testicular cancer
Malignant tumours that form in one or both testes
often detected in the early stages
good prognosis
testes anatomy
semineferous tubule anatomy
Types of germ cell tumours
Seminomas: most common
Yolk sac tumour: most common germ cell tumour in children
Teratomas
Choriocarcinoma
Embryonal carcinoma
seminomas
made of germ cells that multiply without differentiating into other types of cells
germ cells: big with central nuclei surrounded by clear cytoplasm “fried egg”
surrounded by fibrous tissue
placental alkaline phosphatase
Yolk sac tumour
Teratomas
Choriocarcinoma
Embryonal carcinoma
Sex cord/gonadal stromal tumours
Sertoli cell tumours
Leydig cell tumours
Sertoli cell testicular tumours
Leydig cell tumours
Risk Factors for testicular cancer
cryptorchidism
klinefelter syndrome
in utero exposure: pesticides, synthetic sex hormones
genetic
Symptoms for testicular cancer
Complications of testicular cancer
Diagnosis for testicular cancer
Treatment for testicular cancer
Bladder carcinoma
common urogenital cancer
common in the lederly and is strongly associated with smoking
Types of bladder carcinoma
1.urothelial carcinoma (transitional cell carcinoma)
2.Squamous cell carcinoma
3.Adenocarcinoma
Risk Factors for bladder cancer
Signs and symptoms of bladder cancer
Investigations for bladder cancer
Staging of bladder cancer
PET scan/CT scan
Who staging:
Low malignancy potential
Low grade
High grade
Management of bladder cancer
What is polycystic kidney disease?
Condition characterised by development of multiple cysts within the renal tubules. It is the most common hereditary renal disease
Pathophisiology of polycystic kidney disease
1.May begin in utero
2.Size ranges - microscopic to cm
3.Cyst formation + compression -> dysfunctional tubules -> intially compensated
But over time GFR falls -> end stage renal disease
Types of polycystic kidney disease
Autosomal Dominant Polycystic Kidney Disease
Autosomal Recessive Polycystic Kidney Disease
Autosomal Dominant Polycystic Kidney Disease
Autosomal Recessive Polycystic Kidney Disease
Signs and symptoms of polycystic kidney disease
Complications of polycystic kidney disease
Diagnosis of polycystic kidney disease
Treatment for polycystic kidney disease
What is an epididymal cyst?
smooth, extratesticular, spherical cyst in the head of the epididymis
Usually develop around the age of 40
Not uncommon
Rare in children
Pathophisiology of an epididymal cyst
Contain clear and milky (spermatocele) fluid
Lie above and behind the testes
Signs and symptoms of an epididymal cyst
Epididymal cyst differential diagnosis
Diagnosis of an epididymal cyst
Scrotal ultrasound
Treatment of an epididymal cyst
Usually not necessary
If painful and symptomatic then surgical excision
What is a hydrocele
abnormal collection of serous fluid in tunic vaginalis
Types of hydrocele based on aetiology
Congential
Acquired
Acquired can be further subdivided into primary and secondary
What is primary acquired hydrocele
Defective absorption of fluid from tunica vaginalis
Most common hydrocele
Secondary acquired hydrocele
Excessive production of fluid
Causes:
1.Epididymo-orchitis (most common)
2.Torsion of testes
3.Testicular tumours
4.Trauma
Clinical Features of hydrocele
Primary:
Painless, progressive swelling
starts in scrotum (unlike hernia)
penis might be buried in scrotum
Secondary:
Testicular pain prior to swelling (epididymo-orchitis)
Sudden severe testicular pain (torsion)
Lied anterior to and below the testis and will transilluminate
Diagnosis of hydrocele
ultrasound
transilluminate
Treatment for hydrocele
Resolve spontaneously
Many of infancy resolve by 2 years
Therapeutic aspiration or surgical removal
What are lower urinary tract symptoms
Nocturia
Frequency
Urgency
Post-micturition dribbling
Poor stream/flow
Hesitancy
Overflow incontinence
Haematuria
Bladder stones
UTI
Classification of incontinence
overactive bladder (OAB)/urge incontinence: due to detrusor over activity
stress incontinence: leaking small amounts when coughing or laughing
mixed incontinence: both urge and stress
overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
Causes of urge continence
UTIs
CNS disorders: stroke, Parkinsons, MS
Causes of stress incontinence
Increased abdominal pressure: coughing, sneezing, laughing
Pregnancy
Causes of overflow incontinence
Problem with emptying:
-Blockage: BPH, prostate cancer,
-Ineffective detrusor muscle: diabetes mellitus, spinal cord injury, cauda equina syndrome
Incontinence table
Causes of retention
Diffuse proliferative glomerulonephritis
Membranoproliferative glomerulonephritis
Malignant renal tumour
Renal carcinoma
Types of renal carcinoma
Renal cell carcinoma: arises from renal tubule
Transitional cell carcinoma: arises from the renal pelvis
Clinical presentation of renal carcinoma
Haematuria
Abdominal mass
Lethargy
Anorexia
Weight loss
Abdominal pain
Pathophisiology of renal cell carcinoma
Can secrete PTH (hypercalcaemia), ACTH (Cushing like syndrome), EPO (polycythaemia), renin (HTN)
Common metastases: Lymphoma, lung, breast, skin
Common metastases of transitional cell carcinoma
Lymphoma
Lung
Breast
Skin
Causes of renal carcinoma
Smoking
Horshoe kidney
Adult polycystic kidney disease
Kidney failure
Sympotms and signs of renal carcinoma
Passing of blood in urine
Flank pain
Abdominal mass
Diagnosis of renal carcinoma
CT
Abdominal ultrasonography
Treatment of renal cell carcinoma
Surgery
Chemo/radiation therapy
What is chlamydia
It is a sexually transmitted disease caused by a bacteria chlamydia trachomatis
Signs and symptoms of chlamydia
Known as “silent” disease as there are usually no symtpoms
Symptoms appear within 1-3 weeks after exposure
Women:
Vaginal discharge
Pain during urination
Heavier periods
Irregular periods
Bleeding between periods
Pain and bleeding during/after sex
Men:
Pain in testicles
Pain during urination
Swelling of the testicles
Burning/itching of urethra
Pathophisiology of chlamydia
Women: bacteria intially infects the cervix and urethra. then spreads to fallopian tube. chlamydial infection of the cervix can spread to the rectum
Complication of chlamydia
Women:Pelvic Inflammatory Disease
-Pelvic pain
-Infertility
-Ectopic pregnancy
-5x more likely to get HIV
Arthritis
Skin lesions
Reiter’s syndrome
Premature delivery
Treatment for chlamydia
Antibiotics: Azithromycin, doxycycline
Signs and symptoms of gonorrhea
Mostly asymptomatic
Men:
white/green/yellow discharge 1-14 days after infection
Women:
Painful urination
Increased discharge
Bleeding
-can be misdiagnosed as bladder/vaginal infection
Complications of gonorrhea
Women:
Can spread to infect the fallopian tubes/uterus
Causes pelvic inflammatory disease -> can result in infertility/ectopic pregnancy
Men:
Infertility
Pathophisiology of gonorrhoea
Gonorrhoea can spread through the blood via bacteria Neisseria gonorrhoeae
Disseminated Gonococcal Infection (DGI)
-can be life threatening
-causes arthritis
-other forms of inflammation
Diagnosis of gonorrhoea
culturiong a swab specifen in lab
testing swab specimen using nucleic acid amplification testing
Treatment for gonorrhoea
Antibiotics
What is syphilis
Syphilis is a bacterial infection which spread by sexual contact
Sexually transmitted disease
Infection is caused by Treponema pallidum
Stages of syphilis
Primary Stage (3-90 days after infection): stores at original site of infection
Secondary Stage (4-10 weeks after infection)
Latent stage
Tertiary Stage
Signs and symptoms of syphilis
Primary: sores on/around genitals, around anus/rectum, or in and around mouth
Secondary: Skin rash, swollen lymph nodes, fever
Latent stage: no symptoms
Tertiary: development of granulomatous lesions (gummas) in the liver, onset of cardiovascular lesions, characterised by degenerative changes in nervous system
