Renal/Genitourinary Flashcards
1
Q
Describe the parasympathetic, sympathetic and somatic innervation to the bladder respectively
A
pelvic nerve, hypogastric plexus, pudendal nerve
2
Q
LUTS (lower urinary tract symptoms) associated with storage
A
urgency, frequency, nocturia, overflow incontinence
3
Q
LUTS (lower urinary tract symptoms) associated with voiding
A
poor intermittent stream, hesitancy, incomplete emptying, post micturition dribbling, straining
4
Q
What is serum prostate specific antigen (PSA)?
A
A glycoprotein that is expressed by normal and neoplastic prostate tissue, produced to form the fluid in semen
5
Q
In what cases is PSA raised?
A
BPH, prostate cancer, perianal trauma, taller men, recent ejaculation, UTI, prostatitis
6
Q
What does a PSA of >1.4ng/ml indicate?
A
increased risk of LUTS progression (e.g. acute urinary retention)
7
Q
Causes of acute urinary retention?
A
prostatic obstruction (e.g. BPH, prostate cancer), urethral strictures, alcohol, constipation, post-op, infection
8
Q
Cause of chronic urinary retention?
A
prostatic enlargement due to BPH or prostate cancer
9
Q
Treatment for acute urinary retention?
A
catheter, alpha-1 blockers to help relax smooth muscle in the bladder neck
10
Q
What should be considered in any patient with renal impairment?
A
urinary tract obstruction
11
Q
3 classifications of urinary tract obstruction?
A
luminal, mural and extra-mural
12
Q
Diagnosis of urinary tract infection
A
- specific location of pain
- Bloods - U&Es and creatinine raised
- Urinary sample
- Ultrasound
13
Q
Treatment for lower tract urinary obstruction?
A
urethral or suprapubic catheter
14
Q
Advantages of a suprapubic catheter vs a urethral
A
- Less risk of urethral damage and UTI
2. Less likely to be colonised by bacteria in the long-term
15
Q
Treatment for upper tract urinary obstruction?
A
Nephrostomy
16
Q
What is benign prostatic hyperplasia (BPH)?
A
increase in the size of prostate without the presence of malignancy
17
Q
What is the prostate?
A
Accessory gland in the male reproductive system, secretes 70% of the volume of seminal fluid and is hormone dependent, found just below the bladder with the urethra running through it
18
Q
Epidemiology of BPH?
A
common, affects 24% of men aged 40-65, 40% of men >65, affects Afro-Caribbeans more severly than white men
19
Q
What procedure to the testicles is protective of BPH? why?
A
castration, lack of androgens, testosterone does not cause BPH but is required for BPH
20
Q
Clinical presentation of BPH?
A
frequency of micturition, nocturia, delay in initiation of micturition, post-void dribbling, acute urinary retention
21
Q
Pathophysiology in BPH?
A
Benign proliferation of inner layers of prostate, gets bigger, squeezes and may partially block the urethra –> urinary problems
22
Q
Diagnosis of BPH?
A
digital rectal exam (feel enlarged and smooth prostate), serum electrolytes and renal ultrasound, serum PSA (may be raised), biopsy and endoscopy
23
Q
In BPH, how might the prostate feel upon rectal examination?
A
Enlarged and smooth
24
Q
Lifestyle management of BPH?
A
decrease alcohol, caffeine
25
Drugs to treat BPH?
1. Alpha-1 antagonists e.g. tamsulosin to relax smooth muscle in bladder and increase urinary flow
2. 5-alpha reductase inhibitor e.g. finasteride as it blocks the conversion of testosterone to dihydrotestosterone (androgen responsible for prostatic growth)
26
Kidney cancer - most common form
renal cell carcinoma
27
Epidemiology of renal cell carcinoma
Males > females, average age 55
28
Clinical presentation of renal cell carcinoma
haematuria, loin/lumbar pain, mass in flank, malaise, weight loss, fever
29
Investigations for renal cell carcinoma
Ultrasound, CT scan, MRI - staging, renal biopsy
30
Management of renal cell carcinoma?
localised disease - nephrectomy
| metastatic disease - interleukin-2 and interferon lead to remission
31
bladder/urothelial cancer - most common type of which type of carcinoma?
transitional cell carcinoma
32
Epidemiology for bladder/urothelial cancer?
males > females, av age 80
33
Clinical presentation of bladder/urothelial cancer
Painless haematuria, recurrent UTIs, voiding irritability
34
Investigations for bladder/urothelial cancer?
Cytoscopy and biopsy (diagnostic), CT for staging, urinary tumour markers
35
management for bladder/urothelial cancer?
cystectomy, surgical resection, chemotherapy
36
Risk factors for prostatic cancer?
FHx, increasing age, genetic predisposition (HOXB13 gene)
37
Hormonal factors --> prostatic cancer
increased testosterone
38
Clinical presentation of prostatic cancer
bladder outflow obstruction, gland hard and irregular (rectal examination), symptoms due to metastases e.g. bone
39
Investigations for prostatic cancer
transrectal ultrasound and biopsy (diagnostic), digital rectal exam, elevated serum PSA
40
Management for prostatic cancer
Prostatectomy, removal of androgenic drive e.g. bilateral orchidectomy, antiandrogens
41
Risk factors for testicular cancer?
Undescended testes, FHx, infertility
42
Clinical presentation for testicular cancer?
painless lump in testes, testicular/abdominal pain, symptoms due to metastases
43
Investigations for testicular cancer?
Ultrasound, serum concentration of tumour markers
44
Management of testicular cancer
orchidectomy, chemotherapy
45
What is chronic kidney disease?
abnormal kidney function/structure for > 3 months with health implications
46
Epidemiology for CKD?
Risk of CKD increased with age, females > males, often co-exists with CVD and diabetes
47
Classification of CKD?
1. Based on GFR category
2. Presence of albuminuria
3. Cause of kidney disease
48
stage 1 CKD
Normal GFR >90ml/min/1.73m^2
49
What are mesangia lcells
Specialised cells that provide structural support to the glomerular tuft
50
Causes of CKD?
diabetes, glomerulonephritis, HTN, atherosclerotic renovascular disease, acute renal failure
51
Risk factors for CKD?
DM, HTN, old age, CVD, renal stones, BPH, recurrent UTIs, SLE, proteinuria, AKI, smoking, chronic use of NSAIDs
52
Presentation of CKD?
Early stages often asymptomatic (discovered by chance on routine blood/urine test), nausea, vomiting, diarrhoea, fatigue, weight loss, nocturia, polyuria, symptoms due to salt retention (oedema), sexual dysfunction
53
Complications of CKD?
1. Anaemia - due to reduced EPO production by diseased kidney
2. Bone disease - impaired 1,25-hydroxy vit D production
3. Neurological - autonomic dysfunction --> postural hypotension
4. CVD - occurs due to increased frequency of HTN
54
Pathophysiology of CKD?
Irreversible nephron loss, same burden of filtration spread across less nephrons --> nephron failure
55
ECG investigation for CKD?
for high K+
56
CKD urinalysis investigation?
Haematuria, proteinuria, albumin:creatinine ratio
57
CKD investigations - bloods
Raised phosphate and low calcium, low Hb
58
CKD investigations - serum biochemistry
high urea and creatinine, raised ALP, raised PTH
59
Diagnostic investigation for CKD?
Biopsy and histology
60
Management of CKD
Treatment of underlying disease, treatment to slow renal progression (tight glucose control and ACE-i/ARBs), treatment of renal complications of CKD (e.g. anaemia, oedema), treatment of other complications of CKD, prepare for renal replacement therapy
61
Nephrosis
proteinuria due to podocyte pathology
62
Nephritis
haematuria due to inflammatory damage
63
3 broad categories of glomerulonephritis?
1. Conditions that damage the glomerular permeability barrier
2. Conditions that produce severe necrotising glomerular injury
3. Conditions associated with glomerular inflammation, with mesangial/subendothelial immune deposits
64
Conditions that damage the glomerular permeability barrier
produce proteinuria (nephrotic syndrome) - minimal change disease, membranous GN
65
Conditions that produce severe necrotising glomerular injury
cause leakage of blood (haematuria) and protein (proteinuria) into urine, reduced GFR, leads to acute renal failure, crescentic morphology - vasculitis, anti-GBM disease, PGN
66
Crescentic GN
Crescents form - a proliferation of cells within Bowman's space - as a response to capillary rupture with exudation
67
Conditions associated with glomerular inflammation, in association with mesangial and/or subendothelial immune deposits
Lupus nephritis, IgA nephropathy
68
Nephrotic syndrome - epidemiology
rare, DM is the most common secondary cause
69
Tetrad of symptoms for nephrotic syndrome
Proteinuria, hypercholesterolaemia, hypoalbuminaemia, oedema
70
Proteinuria
>3.5g/24hr
71
Pathophysiology of nephrotic syndrome
- Structural and functional abnormalities of podocytes
- Increased filtration of macromolecules across the glomerular capillary wall
- Oedema occurs due to salt retention
72
Causes of primary nephrotic syndrome
minimal change disease, membranous GN, focal segmental glomerulosclerosis
73
Minimal change disease
Commonest form of nephrotic syndrome in children, subtle changes to the glomerular morphology on biopsy, steroids induce remission in most
74
Membranous GN
Histological presence of immune deposits (IgG and C3) on the podocyte side of the GBM with thickening of the capillary wall secondary to production of new BM, most common in adults
75
Focal segmental glomerulosclerosis
Unknown aetiology, sclerosis that is focal and only affects certain glomeruli
76
Secondary causes of nephrotic syndrome
DM, amyloidosis, infections (Hep B/C), SLE, RA, malignancy
77
Diagnosis for nephrotic syndrome
1. Renal biopsy to establish cause
2. Urine dipstick - proteinuria
3. Baseline measurements - albumin, eGFR, glucose
4. Serum tests - Anti-AGM antibodies, ANCA
78
Management for nephrotic syndrome
1. reduce oedema - restrict fluid and salt intake, loop diuretics
2. reduce proteinuria - ACE-i/ARBs
3. Treat underlying cause
4. Reduce risk of complications e.g. statins for hyperlipidaemia
79
Nephritic syndrome
Caused by inflammation to the glomerulus that results in microscopic or macroscopic haematuria, proteinuria and HTN
80
5 'causes' of nephritic syndrome
1. Rapidly progressive GN (RPGN)
2. Anti-GBM antibody GN (Goodpasture's)
3. ANCA associated vasculitis
4. Immune complex mediated GN
5. Membranoproliferative GN
81
Rapidly progressive GN
Any aggressive GN, rapidly progressing to renal failure (not a disease itself), caused by small vessel vasculitis, lupus nephritis, anti-GBM disease, crescents seen in biopsy due to breaks in BGM allowing influx of inflammatory cells
82
Anti-GBM antibody GN (Goodpasture's syndrome)
Autoimmune condition in which the target antigen is on the BM --> production of anti-GBM antibodies --> rapidly progressive GN
83
In some patients with anti-GBM antibody GN, antibodies bind to the antigens in the BM and to?
alveolar capillary BMs, resulting in pulmonary haemorrhage and haemoptysis
84
Goodpasture's syndrome
When RPGN + pulmonary haemorrhage occur
85
ANCA associated vasculitis
Associated with serum antibodies to neutrophil cytoplasmic antigens - ANCA results in nectrotising glomerulonephritis (not associated with immune complex deposition)
86
Immune complex mediated GN
Deposition of immune complexes on GBM
87
Causes of immune complex mediated GN?
IgA nephropathy, post-streptococcal GN, lupus nephritis
88
IgA nephropathy
Defined by the presence of IgA-dominant glomerular deposits, commonest type of GN
89
Membranoproliferative GN
Characterised by mesangial cell proliferation and thickening of the capillary walls with duplications of the basement membranes
90
Presentation of acute nephritic syndrome
Haematuria, proteinuria, HTN and oedema, oliguria
91
Investigations for nephritic syndrome
Renal biopsy for diagnosis, same as nephrotic syndrome
92
Causes of congential renal cysts
Genetic mutation leads to predisposition for cyst formation, there is increased abnormal cell proliferation, cyst initiation, fluid secretion by epithelial cells
93
Causes of renal cysts
acquired over time, CKD, autosomal dominant/recessive polycystic kidney disease
94
Most common type of polycystic kidney disease?
Autosomal dominant
95
Causes of ADPKD?
mutation in either the PKD1 (85%) or PKD2 (15%) gene
96
Pathophysiology of ADPKD
PKD1 and PKD2 encode for the polycystin proteins which are transmembrane proteins which interact to promote the normal development and function of kidneys. The polycystin complex occurs in cilia that are responsible for sensing flow in the tubules, and defective proteins --> defective ciliary signalling --> disorientated cell division --> cyst formation
97
Clinical presentation of ADPKD?
```
excessive water and salt loss (causing problems such as nocturia), loin pain, HTN, bilateral kidney enlargement
renal colic (due to clots), haematuria, renal stones
```
98
Extra-renal manifestations of ADPKD?
Polycystic liver damage, subarachnoid haemorrhage (associated with berry aneurysm formation), pancreatic cysts can cause pancreatitis, male infertility, cardiac abnormalities (mitral valve prolapse)
99
Diagnosis of ADPKD?
Clinical examination - large irregular kidneys, HTN
Ultrasound - detect cysts
In adults with FHx, criteria for diagnosis:
1. at least 2 renal cysts <30
2. 2 cysts per kidney 30-59
3. 4 cysts per kidney 60+
100
Management of ADCKD?
No treatment to slow progression, BP control, analgesia to treat stones, laparoscopic removal of cysts to help with pain
101
Autosomal recessive polycystic kidney disease (ARPKD) - epidemiology?
Less common than ADPKD, disease of infancy and childhood, leads to differing degrees of renal and hepatic involvement
102
ARPKD - later the manifestation of the renal disease, the...
more marked the liver disease (tend to show opposite degrees of severity)
103
Clinical presentation of ARPKD?
variable, presents in infancy with multiple cysts and congenital hepatic fibrosis, enlarged polycystic kidneys, kidney failure
104
Diagnosis of ARPKD
Diagnosed antenatally or neonatally, ultrasound to see cysts, CT and MRI, genetic testing
105
Treatment for ARPKD?
- No treatment
- Family counselling
- Laparoscopic removal of cysts to alleviate pain
- BP control with ACE-i
- Analgesia for stones
106
Erectile dysfunction
persistent inability to attain and maintain an erection
107
Pathophysiology of erectile dysfunction
Neurogenic - failure to initiate
Arteriogenic - failure to fill
Venogenic - failure to store
108
3 arteries supplying the penis
dorsal, cavernous, urethral
109
Causes of erectile dysfunction
age, diabetes, coronary artery disease, dyslipidaemia, trauma, drugs, hypogonadism
110
Examination for erectile dysfunction
height, weight, thyroid exam, pulmonary status, peno-scrotal exam
111
Tests for erectile dysfunction
urinalysis, fasting blood glucose, PSA, prolactin
112
Drugs used to treat erectile dysfunction?
PDE-5 inhibitors
113
Type of patient who will be categorised as having an uncomplicated urinary infection?
Non-pregnant women
114
Types of patients that would fall in complicated category of UTI>
Pregnant, men, catheterised, children, recurrent/persistent infection, immunocompromised
115
What is a UTI?
inflammatory response of the urothelium to bacterial invasion, usually associated with bacteria and pus in the urine
116
Risk factors for UTIs?
Women (pregnancy, post-menopause, new sexual activity), urinary catheters, urinary tract stasis/stones, DM or immunosuppression
117
5 pathogens commonly causing UTIs in a primary setting? (KEEPS)
```
K - Klebseilla spp.
E - E.coli
E - Enterococci
P - Proteus spp.
S - Staphylococcus spp.
```
118
Upper tract UTI?
pyelonephritis
119
Lower tract UTIs?
cystitis, prostatitis, urethritis
120
Uncomplicated UTI?
Normal renal tract structure and function
121
Complicated UTI?
Structural/functional abnormality of the GU tract, leading to decreased renal function
122
Pathophysiology of UTIs?
Contamination of LUT (often due to own gut flora), colonisation in urethra/bladder, inflammatory response, neutrophil infiltration, bacteria evade the immune response, if left untreated may complicate and spread --> kidneys to form an upperTI
123
Clinical presentation of lower UTI?
dysuria, frequency, urgency, haematuria, suprapubic discomfort, cloudy/smelly urine
124
Clinical presentation of upper UTI?
vomiting, fever, flank/loin pain
125
Diagnosis of uncomplicated UTIs?
Diagnosed in those without known abnormalities if they have 2/3 of the classic symptoms and absence of vaginal discharge
126
UTI in pregnancy
Culture rather than dipsticks, positive cultures should be confirmed with second sample, test of cure after one week of treatment
127
Pyelonephritis
Infection of the renal parenchyma and soft tissues of the renal pelvis/upper ureter, classic symptoms - loin pain, pyuria
128
Pyelonephritis investigations
Abdominal examination - tender loin, bloods
129
Pyelonephritis treatment
Fluid replacement, IV antibiotics e.g. co-amoxiclav, drain obstructed kidney ,catheter, analgesia
130
Complications of pyelonephritis
Renal abscess, emphysematous pyelonephritis (life-threatening, rare, gas in tissues)
131
Investigations for UTI?
Dipstick (non-pregnant and <65), mid-stream urine culture, blood tests, imaging
132
Treatment for isolated attack of UTI?
Empirical antibiotics e.g. trimethoprim, or IV antibiotics for an upper UTI
133
Treatment for recurrent UTIs?
Lifestyle advice - drink lots of water, wee before bed and after sex
Catheters - when changing the catheter, treat with prophylactic antibiotics
134
What is HUS/ haemolytic uraemic syndrome?
HUS is a systemic disease caused by damage arising from the circulating toxin which binds to endothelial receptors, particularly in the renal, GI and CNS. RBCs are damaged as they pass through partially occluded small vessels and subsequent haemolysis occurs, the most common cause of AKI in children
135
TTC =
thrombotic thrombocytopenic purpura
136
What is thrombotic thrombocytopenic purpura?
Rare blood disorder that leads to blood clots forming in small vessels throughout the body. "Thrombotic" refers to the blood clots that form. "Thrombocytopenic" means the blood has a lower than normal number of platelets. "Purpura" refers to purple bruises caused by bleeding under the skin
137
Why are NSAIDs nephrotoxic?
Cause vasoconstriction of the afferent arterioles, therefore reduce GFR
138
What is acute kidney injury?
rapid decrease in GFR, leading to abnormal fluid/electrolyte balance, measured by serum creatinine and reduce urine output
139
Current staging system for AKI?
KDIGO - uses serum creatinine and urine output to assess severity
140
KDIGO classification of AKI in terms of creatinine
Stage 1 - Cr 1.5 - 1.9 times the baseline
Stage 2 - Cr 2 - 2.9 x baseline
Stage 3 - >3x baseline
141
Risk factors for AKI?
Pre-existing CKD, elderly, male, nephrotoxic drugs, co-morbidity (CVD, malignancy, chronic liver disease, complex surgery)
142
Pathology of pre-renal AKI and examples for each
1. Hypovolaemia - haemorrhage, burns
2. Reduced CO - cardiogenic shock, MI
3. Systemic vasodilation - sepsis, drugs
4. Renal vasoconstriction - NSAIDs, ACE-i, ARBs
143
Pathology of renal AKI and examples for each
1. Glomerular disease - GN
2. Interstitial disease - drug reaction, infection, infiltration
3. Vascular disease - vasculitis, HUS, TTP
144
Pathology of post-renal AKI and examples for each
1. Within the renal tract - stones, clots, strictures, renal tract malignancy
2. Extra-renal compression - prostatic hypertrophy, pelvic malignancy
145
Pathophysiology of pre, intra and post renal AKI?
Pre-renal - reduced kidney perfusion
Renal - intrinsic kidney disease
Post-renal - obstruction to urine
146
Clinical presentation of AKI
oliguria, may be palpable kidney/bladder, recovery phase lots of dilute urine, arrhythmias due to hyperkalaemia, symptoms of uraemia (fatigue, weakness, confusion, pericarditis), breathlessness (due to combination of anaemia and pulmonary oedema)
147
Diagnosis for AKI
```
Blood count - anaemia, maybe high ESR
Urine dipstick - glomerular disease (haematuria, proteinuria), etc.
Urine and blood cultures
Serum calcium, etc.
Renal ultrasound
Renal biopsy
```
148
Treatment for pre-renal AKI?
Fluids to correct hypovolaemia, treat sepsis with antibiotics
149
Treatment for renal AKI?
Referral to nephrology
150
Treatment for post-renal AKI?
Catheterise, CT scan of renal tract
151
General treatment for AKI
stop nephrotoxic drugs, optimise fluid balance, treat hyperkalaemia (e.g. insulin and glucose to drive K+ into cells), treat pulmonary oedema with diuretics
152
Indications for dialysis? (AEIOU)
```
Acidosis
Electrolyte imbalance
Intoxications
Overload (fluid)
Uraemia
```
153
3 common sites of renal stone deposition?
pelivicureteric junction, pelvic brim, vesicoureteric junction
154
Epidemiology of renal stones?
common, males > females, peak age 20-40, >50% risk of recurrence once had them
155
Risk factors and causes of renal stones
anatomical abnormalities that predisposition to stone formation and blockage, chemical composition of urine that favours crystal formation, dehydration, hypercalcaemia, hyper oxaluria, hypercalciuria, hyperuricaemia, primary renal disease, gout, diet
156
Foods rich in oxalate?
Chocolate, rhubarb, strawberries, tea
157
Why do urinary/renal stones form?
Over-saturation of urine in a context of a trigger that starts crystallisation. In normal urine there are inhibitors of crystal formation
158
Most common type of urinary stones?
Calcium oxalate (60-65%) and calcium phosphate (10%)
159
5 types of urinary stone
calcium oxalate and calcium phosphate, struvite, uric acid, cystine
160
Pathophysiology of calcium stone formation
hypercalcuria (increased calcium in urine)
| hyperoxaluria (increased oxalate in urine)
161
Struvite stones
mixed infective stones (magnesium ammonium phosphate + calcium), usually due to a UTI with an organism that produces urease enzymes. Urease hydrolyses urea --> NH3, which raised alkalinity of urine and this paired with NH3 creates favourable conditions for stone formation
162
uric acid stones
Associated with hyperuricaemia, dehydration, patients with ileostomies are at risk
163
Why are patients with ileostomies at risk of uric acid stone formation?
lower urinary pH, lower urinary volume, higher conc. of Ca2+, uric acid and oxalate
164
Cystine stone formation
associated with homocystinuria, an inherited defect that affects the absorption and transport of cystine
165
Clinical presentation of renal stones?
- May be asymptomatic
- Classic triad - flank/loin pain, vomiting, fever
- Renal colic (SPERN - severe intermittent pain for hours, pain from loin-->groin, excruciating ureteric spasms, rapid onset, nausea and vomiting)
- Urinary frequency, urgency and haematuria
166
Investigations for renal stones
Mid-stream urine test, serum U&Es, creatinine, and Ca2+, X-ray, unenhanced spiral CT scan, urine dipstick, ultrasound
167
Best diagnostic test for kidney stones?
unenhanced spiral CT scan
168
Management for kidney stones?
strong analgesic (IV diclofenac), antibiotics (if infection), stone removal
169
Methods of stone removal for kidney stones?
Extracorporeal shock wave lithotripsy (ESWL), endoscopy with laser
170
What is an epididymal cyst?
Smooth, extra-testicular spherical cyst on the head of the epididymis. Contains clear/milky fluid
171
Epidemiology of epididymal cyst?
Usually develops around 40, relatively common, rare in children
172
Diagnosis and Mxof epididymal cyst?
Scrotal ultrasound, not always necessary to treat, if painful and symptomatic then surgical excision
173
What is hydrocele?
Abnormal collection of fluid within the tunica vaginalis
174
Epidemiology of hydrocele?
Clinically apparent scrotal hydrocele are evident in 6% of males, most paediatric hydroceles are congenital
175
Causes of primary hydrocele?
More common, larger, associated with patent processus vaginalis
176
Causes of secondary hydrocele?
rarer, present in older men, secondary to testis tumour, trauma, infection
177
Pathophysiology of hydrocele?
Overproduction of fluid in the tunica vaginalis, pain isn't a feature unless infection is involved
178
Diagnosis and Mx of hydrocele?
ultrasound, spontaneously resolves, therapeutic aspiration or surgical removal
179
Varicocele
Abnormal dilation of the testicular veins, common cause of low sperm production and quality (can affect fertility)
180
Which scrotum is varicocele more commonly associated with?
Left
| Unusual in boys <10, incidence increases after puberty
181
Causes of varicocele
Defective valves in the veins within the scrotum, normally the valves regulate the flow to and from the testicles, but when this fails, the blood backs up causing the veins to dilate
182
Clinical presentation of varicocele?
Visible as distended scrotal blood vessels, dull ache, scrotal heaviness, scrotum hangs lower on the side of the varicocele
183
Diagnosis and treatment of varicocele?
Venography (x-ray of veins), colour doppler ultrasound to see blood flow, surgery if there is pain
184
What is testicular torsion?
Twisting of the spermatic cord, resulting in occlusion of the testicular blood vessels - can rapidly lead to ischaemia and thus potential loss of testis (germ cells are the most susceptible cell line to ischaemia)
185
Congenital malformation predisposing to testicular torsion
Bell-clapper deformity - testis not fixed to the scrotum completely, allowing for free movement, leading to twisting
186
Clinical presentation of testicular torsion
Sudden onset of severe unilateral testicular pain, associated with nausea and vomiting, pain often comes on during physical activity,
187
How will the testis appear upon examination in testicular torsion?
Testis will have a higher position compared to the contralateral side, with a horizontal lie, may be swollen and tender, cremasteric reflex is absent
188
Diagnosis and Mx of testicular torsion?
Doppler ultrasound (shows lack of blood flow to the testis), urinalysis to exclude infection, no delay of surgical exploration, surgery/ orchidectomy
189
nephrolithiasis
renal stones
190
urolithiasis
urinary stones
191
What is Von-Hippel Lindau syndrome?
An inherited disorder causing multiple tumours of the CNS and visceral organs, autosomal dominant inheritance, 20% of cases caused by new mutations
192
Most common tumours associated with VHL syndrome?
haemangioblastomas (CNS and retinal), phaeochromocytomas, renal cell carcinomas and renal cysts
193
What are the functions of the kidney and what are the implications of kidney damage on them?
1. Blood volume/fluid management - peripheral/central oedema
2. Waste/drug excretion - build up of toxic substances
3. Red cell production (EPO) - can lead to anaemia
4. Vitamin D metabolism - reduced vitamin D, activation of PTH, increased bone resorption
5. Acid-base regulation - acid accumulation and a metabolic acidosis
194
Define glomerulonephritis - what is the difference in presentation between nephrotic and nephritic syndrome?
Glomerulonephritis is any of a group of diseases that injure the glomerulus.
Nephrotic syndrome is characterised by proteinuria, oedema, hyperlipidaemia and hypoalbuminaemia.
Nephritic syndrome is characterised by haematuria, oliguria, and HTN
195
What is the medical emergency associated with AKI? What ECG changes can this commonly cause?
Hyperkalaemia
| On an ECG this appears as tall peaked T waves, reduction of P waves and widening of the QRS complexes
196
4 most common types of urinary stones?
Calcium stones (oxalate and phosphate) - 80%
Struvite 5-10%
Uric acid - 10%
Cystine - 1%
197
5 common symptoms of renal tract stones?
```
(often asymptomatic)
Loin pain (loin-->groin)
Renal colic
UTI symptoms (e.g. dysuria, urgency, frequency)
Recurrent UTIs
Haematuria
```
198
What are the criteria for a 2-week wait referral for suspected bladder cancer
Aged >45 and have:
- Unexplained visible haematuria without UTI or
- Visible haematuria that persists or recurs after successful treatment of UTI
Aged >60 and have:
- Unexplained non-visible haematuria and either dysuria or a raised WCC
199
common symptoms with LUT obstruction in men?
frequency, nocturia, urgency, hesitancy, straining, intermittent stream, incomplete emptying, dribbling
200
What are the two groups of drug commonly used in symptomatic BPH?
alpha-adrenergic antagonists e.g. tamsulosin
| 5-alpha reductase inhibitors e.g. finasteride
201
What issues are there which prevent the PSA test being used routinely for screening?
It is not cancer specific - it can be BPH, UTI, prostatitis
| 6% of men with normal PSA have prostate cancer and 70% of men with a raised PSA will NOT have prostate cancer
202
Commonest presentation of testicular cancer? What differentiates this from a true scrotal mass
A painless testicular lump, hard, does not transilluminate
203
5 medical conditions associated with erectile dysfunction? what is the first line treatment for erectile dysfunction
DM, CVD (MI, HTN), liver disease and alcohol, renal failure, trauma, iatrogenic (prostatectomy).
First line treatment is phosphodiesterase (PDE5) inhibitors
204
Which STI is most commonly diagnosed? How is it tested for and treated?
Chlamydia
Management - partner management, other STI testing, doxycycline bd (twice daily) for 7 days, erythromycin bd for 14 days or azithromycin in pregnancy
205
How is a UTI defined? What constitutes an uncomplicated UTI? Implications of UTI in possible bladder cancer?
Presence of bacteria in the urine with clinical complications. An uncomplicated UTI one occurring in a non-pregnant female. NICE now recommends that those >60 with recurrent/persistent UTIs are referred due to chance of bladder cancer
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Classic triad of symptoms in pyelonephritis? How does its antibiotic treatment differ from that for a lower UTI?
1. Loin pain
2. Fever
3. Pyuria (pus in urine)
In lower tract UTIs broad spectrum antibiotics should be avoided, whereas in upper tract infections they are used first line
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Example of an alpha blocker?
tamsulosin
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Indications for alpha blockers (e.g. tamsulosin)?
1st line treatment for BPH, used alongside 5-alpha reductase inhibitors
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Mechanism of action of tamsulosin/alpha blockers
Highly selective for alpha-1 adrenoreceptors found in smooth muscle (blood vessels and urinary tract). Stimulation of these leads to contraction, therefore inhibition leads to vasodilation (relaxation)
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Adverse effects of alpha blockers (tamsulosin)
postural hypotension, dizziness
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Example of a 5-alpha reductase inhibitor?
finasteride
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What is used to treat BPH in addition to alpha blockers?
5-alpha reductase inhibitors e.g. finasteride
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5-alpha reductase inhibitors e.g. finasteride used to treat BPH?
5-alpha reductase is an enzyme which converts testosterone --> dihydrotestosterone (active form) (reduces androgenic drive enlarging prostate)
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Adverse effects of 5-alpha reductase inhibitors
Sexual dysfunction
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Type of drug used to treat erectile dysfunction? example?
phosphodiesterase-type 5 (PDE5) inhibitors, sildenafil
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How do phosphodiesterase-type 5 (PDE5) inhibitors work?
PDE5 is an enzyme which is found in smooth muscle of the corpus cavernous of the penis (and arteries of the lung), therefore inhibition causes vasodilation and filling of blood
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Adverse effects of PDE5 inhibtors?
flushing, headache, dizziness
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Example of an anti-muscarinic?
Oxybutynin
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How do anti-muscarinics reduce urinary frequency/urgency?
Competitively inhibits ACh, blocking the muscarinic receptors and promoting the bladder relaxation - reduces urgency and frequency of urination
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Androgen receptor blockers are used to treat? Give an example
Prostate cancer since they decrease the body's response to androgens, e.g. flutamide
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Most common STI?
chlamydia, more common in women and those aged 15-25
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Chlamydia trachomatis - gram _________ bacterium
negative
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Neisseria gonorrhoea - gram__________ diplococcus bacterium
negative
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Sites of occurrence of chlamydia and gonorrhoea?
urethra, endocervical canal, rectum, pharynx, conjunctiva
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Complications for chlamydia/gonorrhoea?
Pelvic inflammatory disease, neonatal transmission
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How to test for chlamydia in females? Males?
self collected vaginal swab, first void urine
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Treatment for chlamydia?
PH/partner management, test for other STIs, oral azithromycin stat
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Gonorrhoea treatment?
PH/partner management, test for other STIs, single dose treatment, IM ceftriazone with azithromycin stat
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Parasympathetic (cholinergic) control of the LUT
S3, S4, S5, drives detrusor contraction
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Sympathetic (noradrenergic) control of the LUT?
T10, L1, L2, urethral contraction and inhibition of detrusor muscle contraction
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Varicocele is secondary to other pathological processes blocking the testicular vein e.g.
kidney tumours
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Stress incontinence
Sphincter weakness causing small leak of urine when intra-abdominal pressure rises (coughing, laughing, standing up)
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Treatment of stress incontinence?
pelvic floor exercises, duloxetine, surgery
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Urge incontinence
Strong desire to void and unable to hold urine, caused by detrusor overactivity, bladder hypersensitivity (local pathology e.g. UTI, bladder stones)
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Treatment for urge incontinence
Bladder exercises, behavioural therapy (controlling caffeine, alcohol), drugs (anticholinergic agents, beta 3 agonist
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Primary site of infection of chlamydia and gonorrhoea in males and females respectively?
urethra, cervix
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Basic renal anatomy
- Retroperitoneal organs
- Surrounded by renal capsules
- Between vertebra T12-L3
- Right kidney lower than left
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Tiered kidney arterial supply
Renal artery, segmental artery, interlobar artery, arcuate artery, interlobular artery, afferent arteriole
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Juxtaglomerular apparatus
'detects' the blood pressure and when a decrease in arterial blood pressure is detected via baroreceptors, renin is secreted
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What does the juxtaglomerular apparatus consist of?
Macula densa (DCT), juxtaglomerular cells (afferent arteriole).
Macula densa cells detect sodium concentration, JG cells secrete renin
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Juxtaglomerular cells
Sense changes in renal perfusion pressure by stretch receptors in the vascular walls, they are also stimulated to release renin by signalling from the macula densa
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Complications of CKD
cardiac arrhythmias, HTN, anaemia, renal osteodystrophy (hypocalcaemia, hyperphosphataemia)
243
What tests are repeated within 3 months to confirm CKD diagnosis?
estimated GFR (eGFR) and urine ACR
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What is renal artery stenosis? What is it caused by?
narrowing of one or both of the renal arteries, atherosclerosis, fibromuscular dysplasia
245
Complications of renal artery stenosis?
CKD, coronary artery disease
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Treatment for renal vascular disease
blood pressure control, diuretics initially
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What is renal venous thrombosis? causes?
Occlusion of one or both renal veins by a thrombus, caused by nephrotic syndrome, renal cancer, renal transplant, trauma, dehydration
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Management of CKD
Sodium and fluid restriction, high dose diuretic treatment (furosemide), corticosteroids (prednisolone)
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Why does nephritic syndrome present with HTN?
capillaries of the glomerulus swell, and so the JG cells are stretched even more and this causes an increase in the secretion of renin
250
Causes of RPGN? Treat with...?
small vessel vasculitis, lupus nephritis, anti-GBM disease
treat with corticosteroids
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Anti-GBM antibody GN (Goodpasture's syndrome)
autoimmune condition, antigen on GBM, leads to production of anti-GBM antibodies, often these antibodies bind to the alveolar BM --> pulmonary haemorrhage --> haemoptysis
252
Types of immune complex mediated GN?
IgA nephropathy, post-Streptococcal GN
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Mx for nephritic syndrome
Management depends on cause, FLUID RESTRICTION to reduce oedema, NSAIDS/steroids (reduce inflammation of kidney)
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Term for renal stones?
Nephrolithiasis
255
Gold standard test for nephrolithiasis?
Non-contrast CT kidney-ureter-bladder (CT-KUB)
256
First line treatment for renal stones
'watchful waiting' and analgesia (NSAIDs, e.g. ibuprofen, diclofenac)
257
Common bacteria causing the majority of UTIs?
E.Coli
258
First line Ix for UTI? Gold-standard?
urine dipstick, mid-stream urine analysis
259
1st line antibiotics used in UTIs?
Trimethoprim
260
1st line antibiotics used to treat UTIs in pregnancy?
nitrofurantoin
261
1st line antibiotics in pyelonephritis?
ciprofloxacin
262
Serum biochemical changes seen in AKI?
hyperkalaemia, hyponatraemia, hypocalcaemia
263
Why is hypocalcaemia seen in AKI?
AKI, reduced kidney function, less active form of vitamin D, therefore less Ca2+ absorption
264
Clinical presentation of BPH (LUTS)
Acute urinary retention, haematuria, bladder stones, UTIs
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1st line treatment for BPH?
Oral tamsulosin (alpha-1 antagonist)
266
Gold standard treatment for BPH?
transurethral resection of prostate (can lead to erectile dysfunction)
267
Treatment for metastatic prostate cancer
LHRH, GnRH agonists, androgen receptor antagonists
268
what is neuropathic bladder dysfunction
loss of neuronal control over bladder - two types - spastic injury, flaccid injury
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Spastic injury
Loss of coordination and completion of voiding, bladder only works by reflex, (hyperreflexive), involuntary urination, lose control of voiding
270
Flaccid injury
Hyporeflexive, reflex is lost, fills until it overflows, overflow incontinence, stress incontinence, consider permanent catheterisation
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Left varicocele can be sign of ...
Left kidney cancer
272
BPH vs prostate - difference between how the prostate would feel on DRE?
BPH - smooth enlarged prostate
| Prostate cancer - hard irregular prostate
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Why is using serum PSA levels not recommended by most organisations for screening for prostate cancer?
- doesn't always means prostate cancer
- most men with prostate cancer die from unrelated cause
- some men with fast growing prostate cancer have normal PSA levels
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What type of urinary incontinence can diabetic neuropathy lead to?
Overflow incontinence (due to nerve damage)
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What type of urinary incontinence can a spastic spinal cord injury lead to?
urge incontinence (signal goes to the sacral micturition centre but no higher)
