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Phase 2a high tier list content > Renal/ Genitourinary > Flashcards

Renal/ Genitourinary Flashcards

1
Q

What is the aetiology of renal colic?

A

Upper urinary tract obstruction e.g. from clots

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2
Q

What is the clinical presentation of renal colic?

A
  • Rapid onset pain – woken from sleep
  • Excruciating ureteric spasms
  • Pain from loin to groin that comes and goes in waves
  • Associated with nausea and vomiting
  • Worse with fluid loading
  • Radiates to groin and ipsilateral testis/ labia
  • Often cannot lie still
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3
Q

What is the differential diagnosis of renal colic?

A

Peritonitis

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4
Q

How is renal colic managed?

A

Strong analgesic e.g. IV diclofenac

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5
Q

What is the aetiology of AKI?

pre-renal, intrinsic renal and post-renal

A
  • Rapid decline in GFR
  • Ischaemia, sepsis, nephrotoxins
  • PRE-RENAL = renal hypoperfusion, hypovolaemia (dehydration), low cardiac output (cardiac failure), renal hypoperfusion (NSAIDs)
  • INTRINSIC RENAL = renal parenchyma damage, acute tubular necrosis, vascular (renal artery/vein thrombosis, vasculitis, malignant hypertension), glomerular (glomerulonephritis, autoimmune), interstitial (drugs)
  • POST-RENAL = urinary tract obstruction, stones, clots, malignancy, BPH, strictures, extrinsic compression from malignancy
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6
Q

What is the pathophysiology of AKI?

A

Sustained rise in serum urea and creatinine leading to a failure to maintain fluid, electrolyte and acid-base homeostasis

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7
Q

What are the risk factors of AKI?

A
  • Age > 75y
  • Heart failure
  • Peripheral vascular disease
  • Chronic liver disease
  • Sepsis
  • Poor fluid intake/ increased losses
  • History of urinary symptoms
  • Chronic kidney disease
  • Past history of AKI
  • Hypovolaemia
  • Diabetes
  • Prostate cancer
  • Nephrotoxic drugs
  • Repeated use of radiological contrast
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8
Q

What is the clinical presentation of AKI?

A
  • May be palpable bladder, palpable kidneys, abdominal/pelvic masses and rashes
  • Oliguria (small amount of urine) in early stages
  • Irregular heartbeats
  • Symptoms of uraemia (fatigue, anorexia, nausea, vomiting then confusion, seizures and coma)
  • Breathlessness
  • Pericarditis
  • Impaired platelet function causes bruising
  • Infection
  • Postural hypertension
  • Oedema
  • Thirst
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9
Q

What are the differential diagnoses of AKI?

A
  • Abdominal aortic aneurysm
  • Alcohol toxicity
  • Alcohol and diabetic ketoacidosis
  • Chronic renal failure
  • Dehydration
  • GI bleed
  • Heart failure
  • Metabolic acidosis
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10
Q

How is AKI diagnosed?

A
  • Rising serum urea and creatinine
  • Urine dipstick (can suggest infection and glomerular disease)
  • Blood count (anaemia and high ESR = myeloma or vasculitis)
  • Mid-stream urine specimen
  • Renal USS (assessment of kidney size and distinguish obstruction, look for abnormalities)
  • CT of kidneys, ureters and bladder (CT-KUB) (see if obstruction causing no urine – relieved by catheter)
  • ECG – for hyperkalaemia changes
  • CXR – for pulmonary oedema)
  • Renal biopsy
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11
Q

How is AKI managed?

A
  • Treat underlying cause – pre-renal (fluids, antibiotics), intrinsic renal (refer early to nephrology), post-renal (catheterise and CT renal tract)
  • Stop nephrotoxic drugs (NSIADs, ACEi, gentamicin)
  • Optimise fluid balance
  • For hyperkalaemia give calcium gluconate and insulin and glucose
  • Treat acidosis with sodium bicarbonate
  • Treat pulmonary oedema with diuretics
  • Diet – Na+, K+ restriction, vitamin D supplement
  • Renal replacement therapy (hemofiltration, haemodialysis, transplant)
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12
Q

What is the aetiology of kidney cancer?

A
  • Smoking
  • Obesity
  • Hypertension
  • Renal failure and haemodialysis
  • Polycystic kidneys
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13
Q

What is the pathophysiology of kidney cancer?

A
  • Malignant cancer of proximal convoluted tubular epithelium

- Spread can be direct (renal vein), by lymph nodes or haematogenous (bone, liver, lung)

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14
Q

What are the risk factors of kidney cancer?

A
  • Smoking
  • Obesity
  • Hypertension
  • Renal failure and haemodialysis
  • Polycystic kidneys
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15
Q

What is the clinical presentation of kidney cancer?

A
  • Often asymptomatic and found incidentally
  • Haematuria, flank pain, abdominal mass
  • Anorexia, malaise, weight loss
  • Sometimes invasion of left renal vein causing a varicocele
  • Polycythaemia
  • Hypertension
  • Anaemia
  • Fever
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16
Q

What are the differential diagnoses of kidney cancer?

A
  • Transitional cell carcinoma
  • Wilms’ tumour
  • Renal oncocytoma
  • Leiomyosarcoma
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17
Q

How is kidney cancer diagnosed?

A
  • Renal USS (distinguish cyst from tumour)
  • CT chest and abdomen with contrast (detect renal mass – contrast demonstrates kidney function)
  • MRI (tumour staging)
  • BP (increased from renin secretion)
  • FBC (polycythaemia, anaemia from EPO decrease)
  • ESR (raised)
  • LFT may be abnormal
  • Renal biopsy
  • Bone scan
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18
Q

How is kidney cancer managed?

A
  • Localised = surgery (nephrectomy or partial)
  • Ablative techniques e.g. cryoablation and radiotherapy (if lots of comorbidities so can’t have surgery)
  • Metastatic or locally advanced = interleukin-2 and interferon alpha first line
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19
Q

What is the carcinoma type of bladder cancer?

A

Transitional cell carcinoma (most common type of TCC)

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20
Q

What is the pathophysiology of bladder cancer?

A

Tumour spread:

  • Local → pelvic structures
  • Lymphatic → iliac and para-aortic nodes
  • Haematogenous → liver and lungs
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21
Q

What are the risk factors of bladder cancer?

A
  • Smoking
  • Occupational exposure to carcinogens (esp. petroleum, chemical, cable and rubber industries)
  • Exposure to drugs (cyclophosphamide)
  • Chronic inflammation of urinary tract (e.g. from Schistomiasis)
  • > 40y
  • Male
  • Family history
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22
Q

What is the clinical presentation of bladder cancer?

A
  • Painless haematuria (maybe pain from clot retention)
  • Recurrent UTIs
  • Voiding irritability
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23
Q

What are the differential diagnoses of bladder cancer?

A
  • Haemorrhagic cystitis
  • Renal cancer
  • UTI
  • Urethral trauma
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24
Q

How is bladder cancer diagnosed?

A
  • Cystoscopy with biopsy (diagnostic)
  • Urine microscopy/ cytology
  • CT urogram – staging
  • Urinary tumour markers
  • MRI to see involved pelvic nodes
  • CT/ MRI of pelvis
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25
How is bladder cancer managed? | Non-muscle invasive, localised muscle invasive and metastatic
NON-MUSCLE INVASIVE: surgical resection ± chemotherapy (mitomycin, doxorubicin and cisplatin) LOCALISED MUSCLE INVASIVE: radical cystectomy, post-op chemo, radical radiotherapy (if not fit for surgery), chemo METASTATIC: palliative chemotherapy and radiotherapy
26
What is the aetiology of prostate cancer?
Hormonal factors e.g. increased testosterone
27
What is the pathophysiology of prostate cancer?
- Most are adenocarcinomas in the peripheral prostate - Androgen receptors on the prostate are responsible for cancerous growth Tumour spread: - Local → seminal vesicles, bladder, rectum - Lymph - Haematogenous → bone, brain, liver lung
28
What are the risk factors of prostate cancer?
- Family history (3+ affected relatives or 2 with early onset) - Genetic (HOXB13) - Increasing age - Black ethnicity
29
What is the clinical presentation of prostate cancer?
- LUTS if local disease (nocturia, hesitancy, poor stream, terminal dribbling, obstruction) - Weight loss, bone pain and anaemia suggest metastasis
30
What are the differential diagnoses of prostate cancer?
- BPH - Prostatitis - Bladder tumours
31
How is prostate cancer diagnosed?
- DRE – hard, irregular prostate - Raised PSA - Trans-rectal ultrasound (TRUS) and biopsy – diagnostic - Urine biomarkers (PCA3 or gene fusion protein) - Endorectal coil MRI to locally stage
32
How is prostate cancer managed?
- LOCAL: radical proctectomy, radiotherapy + hormone therapy, brachytherapy (implantation of radioactive material targeted at tumour), hormone therapy temporarily, active surveillance (if >70y and low risk) - METASTATIC: endocrine therapy (androgen deprivation) – orchidectomy (testes removal), LHRH agonists, androgen receptor blockers) - Analgesia - Treat hypercalcaemia - Radiotherapy for bone metastases/ spinal cord progression
33
What cells do testicular cancers arise from?
- 96% arise from germ cells | - 4% arise from non-germ cells
34
What are the risk factors of testicular cancer?
- Undescended testes - Infant hernia - Infertility - Family history
35
What is the clinical presentation of testicular cancer?
- Painless lump in testicle, testicular pain and/or abdominal pain - Hydrocele - Cough and dyspnoea (indicative of lung metastases) - Back pain - Abdominal mass
36
What are the differential diagnoses of testicular cancer?
- Testicular torsion - Lymphoma - Hydrocele - Epididymal cysts
37
How is testicular cancer diagnosed?
- USS to differentiated between masses in the body of the testes and other intrascrotal swellings - Biopsy and histology - Serum tumour markers - CXR and CT for staging
38
How is testicular cancer managed?
- Radical orchidectomy via inguinal approach - Radiotherapy for seminomas with metastases below diaphragm - Chemotherapy for more widespread tumours and teratomas - Sperm storage offered
39
What is the aetiology of CKD?
- Diabetes mellitus (2>1) - Hypertension - Atherosclerotic renal vascular disease - Polycystic kidney disease - Tuberous sclerosis - Primary glomerulonephritides (e.g. IgA nephropathy) - SLE - Amyloidosis - Hypertensive nephrosclerosis - Small/medium vessel vasculitis - Family history of stage 5 CKD or hereditary kidney disease - Hypercalcaemia - Neoplasma - Myeloma - Idiopathic
40
What is the pathophysiology of CKD?
- Many nephrons have failed and scarred so the burden of filtration falls to fewer functioning nephrons - Increased flow per nephron raises intraglomerular capillary pressure which accelerates nephron failure - Increased strain can be detected as new/ increasing proteinuria
41
What are the risk factors of CKD?
- Diabetes mellitus - Hypertension - Old age - CVD - Renal stones or BPH - Recurrent UTIs - SLE - Proteinuria - AKI - Smoking - African, afro-Caribbean or Asian origin - Chronic NSAID use
42
What is the clinical presentation of CKD?
- Early stages are often asymptomatic - Malaise - Anorexia and weight loss - Insomnia - Nocturia and polyuria - Itching - Nausea, vomiting and diarrhoea - Peripheral/ pulmonary oedema - Amenorrhea in women - Erectile dysfunction in men - Increased risk of peptic ulceration, acute pancreatitis, hyperuricaemia and incidence of malignancy
43
What is the differential diagnosis of CKD?
AKI
44
How is CKD diagnosed?
- ECG for high potassium - URINALYSIS: haematuria, proteinuria, mid-stream urine sample, albumin to creatinine ratio - URINE MICROSCOPY: white cells = UTI; eosinophilia = allergic tubulointerstitial nephritis;, granular cells = active renal disease; red cells = glomerulonephritis - SERUM BIOCHEMISTRY: U&E raised, low eGFR, raised alk phos, raised PTH (if CKD > stage 3) - BLOODS: raised phosphate, low Ca2+, low Hb - IMMUNOLOGY: auto-antibody screening for SLE, Hep B, C and HIV antigen tests - IMAGING: USS to check renal size, CT to detect stones, retroperitoneal fibrosis and other causes of urinary obstruction
45
How is CKD managed? | limiting progression, symptom control and renal replacement therapy
- Aims to slow deterioration of kidney function, reduce cardiovascular risk and treat complications - Identify and treat reversible causes (relieve obstruction, stop nephrotoxic drugs, stop smoking, tight glucose control in diabetes) - LIMIT PROGRESSION AND COMPLICATIONS: BP (ACEi, ARB, diuretic, CCB), bone disease (treat raised PTH, restrict diet, vitamin D, phosphate binders), CVD (statins and aspirin) - SYMPTOM CONTROL: anaemia (iron/ folate/ folic acid), acidosis (sodium bicarbonate), oedema (furosemide) - RENAL REPLACEMENT THERAPY: hemofiltration, haemodialysis, peritoneal dialysis, transplant
46
What is the aetiology of benign prostate hyperplasia?
Increased in size of prostate without a malignancy
47
What is the pathophysiology of benign prostate hyperplasia?
- Benign nodular or diffuse proliferation of musculofibrous and glandular layers of the prostate - Inner (transitional) zone enlarges in contrast to peripheral layer expansion - As prostate gets bigger, it may squeeze or partly block the urethra
48
What are the risk factors of benign prostate hyperplasia?
- Increasing age | - Castration is protective (testosterone is a requirement for BPH)
49
What is the clinical presentation of benign prostate hyperplasia?
- LUTS (nocturia, frequency, urgency, post-micturition dribbling, poor stream/flow, hesitancy, overflow incontinence, haematuria, bladder stones, delay in initiation of micturition, incomplete emptying of bladder) - Enlarged bladder on abdominal exam - Acute urinary retention - Can cause anuria (no urination) if BPH causes bladder to become occluded - NO erection problems
50
What are the differential diagnoses of benign prostate hyperplasia?
- Bladder tumour - Bladder stones - Trauma - Prostate cancer/ chronic prostatitis - UTI
51
How is benign prostate hyperplasia diagnosed?
- DRE – enlarged but smooth prostate - Serum electrolytes and renal USS to exclude renal damage from obstruction - TRUS – prostate size - PSA may be raised in large BPH - Biopsy and endoscopy - Mid-stream urine sample to exclude infection - Flow rates and residual volume - Frequency volume chart
52
How is benign prostate hyperplasia managed?
- Watchful waiting if minimal symptoms - Lifestyle advice: no caffeine or alcohol, relax when voiding, void twice in a row - Drugs in mild disease or pre-surgery: alpha-1 antagonists e.g. oral tamsulosin (first line), 5-alpha-reductase inhibitor e.g. oral finasteride - Surgery for large prostate or no response to other treatments: transurethral resection of prostate (TURP) or transurethral incision of prostate (TUIP)
53
What is the aetiology of pyelonephritis?
- Infection of renal parenchyma and soft tissues of renal pelvis and upper ureter - Majority caused by uropathogenic E.coli - Others = klebsiella, enterococcus, proteus, staphylococcus
54
What is the pathophysiology of pyelonephritis?
- Infection due to bacteria from patient’s bowel flora | - More common via ascending transurethral route (can also be via bloodstream or lymphatics)
55
What are the risk factors of pyelonephritis?
- Structural renal abnormalities - Calculi (stones) - Catheterisation - Pregnancy - Diabetes - Immunocompromised
56
What is the clinical presentation of pyelonephritis?
- Loin pain, fever, pyuria - May have a severe headache - Rigors - Significant bacteriuria - Malaise, nausea, vomiting - Oliguria if causes AKI
57
What are the differential diagnoses of pyelonephritis?
- Diverticulitis - Abdominal aortic aneurysm - Kidney stones - Cystitis - Prostatitis
58
How is pyelonephritis diagnosed?
- Tender loin on examination - Urine dipstick: nitrates, leucocyte elastase, foul-smelling, protein - Midstream urine microscopy, culture and sensitivity - FBC – elevated WCC - CRP and ESR raised in acute infection - Urgent USS for calculi, obstruction, abnormal anatomy
59
How is pyelonephritis managed?
- Rest - Cranberry juice and lots of water - Analgesia - Antibiotics (oral ciprofloxacillin or oral co-amoxiclav) – is severe then IV gentamicin or IV co-amoxiclav - Surgery to drain abscesses or relieve calculi that are causing infection
60
What is the aetiology of cystitis?
- Urinary infection of the bladder | - Most commonly caused by E. coli
61
What are the risk factors of cystitis?
- Urinary obstruction resulting in urinary stasis - Previous damage to bladder epithelium - Bladder stones - Poor bladder emptying
62
What is the clinical presentation of cystitis?
- Dysuria - Frequency - Urgency - Suprapubic pain - Haematuria - Offensive smelling/ cloudy urine - Abdominal/ loin tenderness
63
How is cystitis diagnosed?
- Microscopy and sensitivity of sterile mid-stream urine | - Dipstick urinalysis (positive blood, nitrates and leucocytes)
64
How is cystitis managed?
Antibiotics - First line: trimethoprim or cefalexin - Second line: ciprofloxacin or co-amoxiclav
65
What is the aetiology of acute prostatitis?
- Streptococcus faecalis - E.coli - Chlamydia
66
What is the aetiology of chronic prostatitis? | bacterial and non-bacterial
BACTERIAL (e.g. streptococcus faecalis, E.coli, chlamydia) NON-BACTERIAL (e.g. elevated prostatic pressure, pelvic floor myalgia)
67
What are the risk factors of prostatitis?
- STI - UTI - Indwelling catheter - Post-biopsy - Increasing age
68
What is the clinical presentation of acute prostatitis?
- Systemically unwell - Fever - Rigors - Malaise - Pain on ejaculation - Significant voiding LUTS - Pelvic pain
69
What is the clinical presentation of chronic prostatitis?
- Acute symptoms for >3m - Recurrent UTIs - Pelvic pain
70
What are the differential diagnoses of prostatitis?
- Cystitis - BPH - Calculi - Bladder neoplasia - Prostatic abscess
71
How is prostatitis diagnosed?
- DRE – tender, hot, tough prostate, hard from calcification - Urine dipstick (positive for leucocytes and nitrates) - Mid-stream urine microscopy and sensitivity - Blood cultures - STI screen - TRUSS
72
How is acute prostatitis managed?
IV gentamicin + IV co-amoxiclav or IV tazocin or IV carbapenem 2-4w on a quinolone once well (2nd line trimethorpin) TRUSS guided abscess drainage if necessary
73
How is chronic prostatitis managed?
4-6w quinolone e.g. ciprofloxacin ± alpha blocker NSAIDs
74
What is the aetiology of urethritis?
- Primarily a sexually acquired disease - Chlamydia trachomatis (most common) - Neisseria gonorrhoea - Trauma, urethral stricture, irritation, urinary calculi
75
What are the risk factors of urethritis?
- Sexually active - Unprotected sex - Male-with-male sex - Male
76
What is the clinical presentation of urethritis?
- May be asymptomatic - Dysuria ± discharge, blood or pus - Urethral pain - Penile discomfort - Skin lesions - Systemic symptoms
77
What are the differential diagnoses of urethritis?
- Candida balanitis - Epididymitis - Cystitis - Acute prostatitis - Urethra; malignancy
78
How is urethritis diagnosed?
- Nucleic acid amplification test (NAAT) – female = self-collected vaginal swab; male = first void volume - Microscopy of gram-stained smears of genital secretions - Blood cultures - Urine dipstick to exclude UTI - Urethral smear
79
How is urethritis managed?
- Patient education - Contact tracing CHLAMYDIA: - Oral azithromycin state or 1w oral doxycycline - Test for other STIs GONORRHOEA: - IM ceftriaxone with oral azithromycin - Partner notification

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