Renal & GU Flashcards
Tx of BPH
Tamsulosin
Finasteride
Action of tamsulosin
& what class of drug is it?
Relax smooth muscle of bladder and prostate
∴ ↑ Urine flow rate
(selective alpha-1-adernergic receptor antagonists)
S/E of tamsulosin
Postural instability, retrograde ejaculation
Findings on DPE of BPH
Smooth, enlarged prostate
Findings of DPE of Prostate cancer
Hard and irregular
Ix for BPH
(incl values if measuring any antigens cough cough)
Digital Rectal Examination
Prostate-Specific antigen > 1.5ng/mL
GS (?) : Trans-rectal US
Ix for Prostate cancer
(no abbrv)
Digital Rectal Exam
Prostate Specific Antigen
Trans-rectal US
Prostate biopsy
What’s the grading thing called for prostate cancer?
Gleason grading score
Most common pathogens for UTIs
E.Coli
Proteus
Why is creatinine used as a marker of GFR?
Freely filterised
Not metabolised
Not secreted
Not reabsorbed
Mechanism of loop diuretics
Where do they act upon?
Act of ascending limb of loop of Henle
Inhibit Na+/K+/2Cl- co-transporter
(bc if it transports ions, water will follow)
Examples of loop diuretics
Furosemide
Bumetanide
S/E Loop diuretics
Dehydration
Hypotension
Hypokalaemia
& Metabolic alkalosis can occur !
If v high doses, can cause ototoxicity
Give an example of K+ sparing diuretic
Amiloride
Spironolactone
Mechanism of K+ sparing diuretics
Where do they act upon?
Act on the distal convoluted tubule
Inhibits reabsorption of sodium (and ∴ water) by epithelial sodium channels
∴ Na+ and H2O excretion
(and K+ retention)
S/E K+ sparing diuretics
GI upset
Hyperkalaemia
Metabolic acidosis
Gynecomastia
Example of a thiazide diuretic
Bendroflumethiazide
Mechanism of Thiazide diuretic
Where does it act upon?
Acts on sodium/chloride transporter
Prevents it from functioning properly
∴ Sodium is NOT retained
Compare thiazide and loop diuretics
(In terms of length and efficacy)
Thiazide diuretics are longer acting
But not as effective as loop
S/E Thiazide diuretics
Hypokalaemia
Metabolic alkalosis
Hypovolaemia
Hyponatraemia
Hyperglycaemia in DM
Where does Angiotensin II act on?
PCT
What does Angiotensin II do?
Causes thirst
↑ SNS activity
ADH release (by stimulating post. pituitary)
Aldosterone release (by stimulating adrenal glands)
↑Proximal tubule reabsorption which ↑Na+ reabsorption
Causes vasoconstriction to ↑BP
ESSENTIALLY, ↑BP
Where does Aldosterone act?
On DCT and collecting ducts
What does Aldosterone do?
↑Na+ reabsorption
↑K+ secretion
Binds to cytoplasmic receptors - transported to nucleus
↑Epithelial Na channels
↑Na+/K+ ATPase
↑Effective circulating vol
Where does ADH act on?
Distal tubule
Collecting ducts
What does ADH do?
Acts on V1 receptors on blood vessels to cause vasoconstriction
Acts on V2 receptors in basolateral side of collecting ducts
↑ Insertion of aquaporin 2 on apical membrane of collecting ducts
∴ ↑ Water reabsorption
Also, helps maintain hypertonicity of medulla by ↑urea permeability of collecting ducts
What is ADH produced by?
Hypothalamus
Where is ADH released?
Post. pituitary
What triggers ADH release?
Increased plasma osmolality
(↓ water)
What detects decreased water in the body? How?
Hypothalamic osmoreceptors
Detects bc H2O diffuses out post. pituitary in response to ↑Na+ pulling it out
What is ANP?
Atrial Natriuretic Peptide
What is the aim of ANP?
To decrease BP
(inhibits renin secretion)
When is ANP released ?
When atria are stretched (due to high BP), it causes ANP to be released
What are the actions of ANP?
Dilates aff glomerular arterioles
Constricts eff glomerular arteriole
Relaxes mesangial cells (to ↑GFR) - so excretion can be increased
“Blocks” NCC in DCT and ENaC in CT
∴ prevents reabsorption and ↑Na+ excretion
↑Vasa recta blood flow - leads to less reabsorption
SYSTEMIC VASODILATOR
Where is parathyroid hormone released from?
In response to what?
Parathyroid glands
In response to ↓Ca2+ plasma levels
What does PTH do?
↑ Ca2+ reabsorption
↑ HPO4^3- excretion
Stimulates formation of Vit D
Describe the activation of Vitamin D
Where can kidney stones be deposited?
Anywhere from renal pelvis to ureter
Where are kidney stones formed?
Collecting ducts
RF Renal Colic
Male (M:F 2:1)
Middle East - due to higher oxalate, lower Ca2+ diet and ↑dehydration
What is renal colic also known as?
Nephrolithiasis
Where the most common sites for renal stones to get stuck?
Pelviureteric junction (PUJ) - MC !
Pelvic brim
Vesicoureteric junction (VUJ)
Causes Renal Colic
ANATOMICAL ABNORMALITIES
Congenital - horseshoe, duplex, PUJ, spina bifida
Acquired - obstruction, trauma, reflux
URINARY
Metastable urine
Ca2+, oxalate, urate, cystine
Dehydration
INFECTION-INDUCED STONES (struvite) - UTI w organisms that produce urease, is assoc/ with struvite stones
Proteus, klebsiella, pseudomonas
HYPERCALCIRURIA
In turn, caused by:
Hyperparathyroidism - MC !!!
Hypercalcaemia
XS dietary calcium
XS resorption of calcium from bone (immobilisation)
Idiopathic hypercalciuria
HYPEROXALURIA
↑ dietary intake of oxalate rich foods e.g. spinach, rhubarb, tea
ALSO, ↓dietary calcium intake
(bc means decreased binding of oxalate w/ Ca2+)
Signs / Symptoms Renal Colic
Can be asymptomatic
Loin to groin colicky pain - peristaltic waves
Severe, unilateral, worse than labour!
Rapid onset (mins-hours)
Unable to get comfy - writhing in agony
Worse w fluid loading
N+V
Sweating
Fever
UTI Sx !! - Dysuria, burning when urinating, urgency, frequency
Haematuria (visible and non-visible)
Recurrent UTIs
Rigors
Bladder/urethral stones
Ix Renal Coli
Detailed history - might reveal cause of stone e.g. lots of tea = high oxalate
1st line - XR KUB
(easy and cheap)
GS!!! NON-CONTRAST CT KUB
vvv spec (99%)
US - useful for pregnancies and young (no radiation)
Sens for hydronephrosis
Urine dipstick - traces of blood
Mid-stream specimen
follow up with MSU if pos
Bloods - FBC, U&E, calciu, uric acid
What benefits does Non-Contrast CT have over CT w contrast?
Good for allergies (doesnt trigger)
and no renal damage
Tx Renal Colic
Hydration
STRONG ANALGESIC - IV diclofenac
NSAIDs, IV paracetamol, +/- opiates!
Anti-emetics - metoclopramide
+/- IV fluids - might make pain worse as diuresis happens
Conservative - allow 2 weeks to pass
Abx if UTI
Medical expulsive therapy? Not much evidence if it works
Extracorpeal Shock Wave Lithotripsy (ESWL) - if <1 cm
Surgery - Ureteroscopy, Percutaneous Nephrolithotomy (PCNL), Nephrectomy
ADMIT IF SHOCK, FEVER, SEPSIS, PREGNANCY ETC
Types of Stones
Calcium oxalate - form in acidic urine, MC !!!!
Calcium phosphate - alkali urine
Calcium carbonate
Struvite - proteus, Klebsiella, pseudomonas bacteria
Uric acid
Cystine
Drug precipitants
Why are Kidney stones treated more conservatively?
Small, safe location
More asymptomatic
Static size
Lifestyle changes for prevention Renal Colic
↓Dietary salt
Normal dairy intake
Lose weight
Active lifestyle
Overhydration
Stop smoking
More citrus fruit
With renal colic, when might a stone pass spontaneously?
If small <5mm
How might you treat renal colic if it’s a large stone?
ESWL
Ureteroscopy
PCNL
Comps Renal Colic
HYDRONEPHROSIS - requires surgical drainage
AKI Criteria for diagnosis
↑ Creatinine > 26 mmol/L in 48 hours above baseline
↑ Creatinine > 50% (best fig in last 6 months)
Urine output < 0.5ml/kg/hour for > 6 consec hours
Define AKI
Abrupt deterioration (hours to days) in renal function
Due to rapid decline in GFR
Leading to a failure to maintain fluid, electrolyte, acid-base homeostasis
Usually but not always reversible
Decreased in function < 3 months?
What is AKI assoc with?
Diarrhoea
Haematuria
Haemoptysis
Hypotension
Urine retention
Causes AKI
PRE-RENAL - ↓blood flow to kidney ∴ ↓ GFR
Shock
Hypovolaemia ! - diarrhoea, vomiting, trauma, bleeding, diuretics, burns
Hypotension - cardiogenic shock, sepsis, anaphylaxis
Cardiovascular - HF, severe arrhythmias
Sepsis
Renal hypoperfusion - NSAIDs, ACEi, ARBs
RENAL - cells damaged so kidney can’t filer blood properly
Acute tubular necrosis
Nephrotoxins - NSAIDs, Methotrexate
Glomerulonephritis
Acute interstitial nephritis
Infection
Vasculitis
Malignant HTN
Autoimmune disease
POST-RENAL - anything that causes blockage of kidney
BPH
Kidney stones
Cancer
Blood clot
RF AKI
Age > 75 years
DM
HF
Sepsis
Peripheral vascular disease
Drugs
FHx
Poor fluid intake/loss
DDx Nephrolithiasis
Aortic abdo aneurysm
Diverticulitis - L sided
Appendicitis - R sided
Pyelonephritis
Acute pancreatitis
Ectopic preg
Testicular torsion
Peritonitis
Signs / Symptoms AKI
Often asymptomatic!! Esp early stages
Fluid overload - oliguria/anuria, pulmonary/peripheral oedema, palpable bladder, hypovolaemic shock, ↑JVP,
Hyperkalaemia - arrhythmias, muscle weakness, tachycardia
Hyperuraemia - N+V, weakness, tremor, pericarditis, platelet dysfunction (bleeding), confusion and seizures if severe
Metabolic acidosis
Postural hypotension
Thirst
Poor tissue turgor
When is AKI a medical emergency?
Hyperkalaemia!!
What ECG signs are associated with hyperkalaemia?
Tall peaked T waves
Wide QRS
Small P waves
Ix AKI
Urine dipstick - blood, nitrites, leukocytes, glucose, protein
Bloods - FBC, U&Es, creatinine, liver enzymes
Renal US - for obstruction
Renal biopsy - for intra renal cause
Monitor urine output
Non-contrast CT KUB
KUB CR
Autoantibodies - Anti-GBM, ANCA
Tx AKI
Treat underlying cause
Pre-renal - correct vol depletion w fluids, treat sepsis w Abx
Intra-renal - maybe refer if concern over glomerular/interstitial pathology
STOP NEPHROTOXIC DRUGS ! - NSAIDs, ACEi, ARBs, lithium, digoxin
Treat underlying comps - hyperkalaemia, pulmonary oedema etc
IF severe - dialysis
What is refractory pulmonary oedema?
When AKI is esp bad, kidneys stop producing urine
That fluid can end up in lungs!
Describe some differences between AKI and CKD
AKI
Normal sized kidneys
No anaemia
No DM
↓ BP
Rapid change
Oliguria usually
Not often CNS symptoms
Presents more like shock
CKD
Small kidneys!
Anaemia
DM
↑BP
Gradual onset
Oliguria only in later stages
CNS symptoms in later disease
Presents like serious extensive disease
Chronic Kidney Disease Definition
Long-standing and progressive pathological abnormality of the kidney FOR AT LEAST 3 MONTHS
Pathophysiology Renal Colic
Stones form from crystals in supersaturated urine
Occurs when solute is too conc - increase in solute or decrease in solvent (dehydration)
Causes CKD
HTN
DM (more T2 than T1)
Polycystic kidney disease
SLE
Nephrotoxic drugs, chronic NSAID use
Obstructive uropathy - kidney stones, enlarged prostate
Progression from AKI
Glomerular disease / Chronic glomerulonephritis
SLE
Atherosclerotic renal vascular disease
Tuberous sclerosis
Malignancy - myeloma
CKD Diagnostic Criteria
eGFR < 60 ml/min/1.73m2
eGFR < 90ml/min/1.73m2 + signs of renal damage
Albuminuria > 30mg/24hours
(albumin:creatinine > 3mg/mmol)
RF CKD
DM
HTN
Female?
Age
Smoking
Polycystic kidney disease
NSAIDs
Cardiovascular disease - IHD, LV hypertrophy
FHx
Signs / Symptoms CKD
Early stages = Asymptomatic
Arise as GFR declines
–
Urinary - oliguria! haematuria, proteinuria, nocturia, polyuria
Bone disease! - Osteomalacia, osteoporosis
Anaemia!
Bilaterally small kidneys!!
Increased skin pigmentation! (yellow tinge)
HYPERKALAEMIA
N+V, fatigue, malaise, anorexia, itching, hiccups, convulsions, tremors, pallor
CVD - Uraemic pericarditis
Neuro - confusion, coma, fits
Vol overload - SOB (pulmonary oedema, dyspnoea, ankle oedema)
Sexual dysfunction
Describe the mechanism of HTN as a cause for CKD
Walls thicken in order to withstand pressure
∴ narrow lumen
∴ less blood and O2 to kidney
∴ ischaemic injury
Immune cells travel into damaged glomerulus and release TGF-B1
Then, mesangial cells regress to immature cells + excrete extracellular matrix
∴ GLOMERULOSCLEROSIS (kidney is scarred)
∴ ↓ ability for nephron to filter blood
Describe the mechanism of DM as a cause for CKD
Type 2 > Type 1
XS glucose in blood sticks to proteins - esp effects efferent arteriole making it stiff and narrow
∴ obstruction for blood leaving glomerulus
∴ hyperfiltration
∴ mesangial cells secrete more structural matrix
∴ ↑ size of glomerulus
∴ Glomerulosclerosis
Eventually becomes CKD
Quick!!!! Presentation CKD
Early asympto
Normochromic, normocytic anemia
Bone disease ! - osteomalacia
HTN
Fluid overload - oedema
CVD - cardiomyopathy
Malaise, loss of appetite, oliguria, haematuria
Ix CKD
FBC - shows anaemia, ↑ creatinine and urea levels
+ ↓ Ca2+ , ↑ phosphate, PTH, K+
Urinalysis
Dipstick (haematuria and proteinuria ~ GN, leukocytes and nitrites ~ infection)
Urine & blood culture - to exclude infection
White cells - bacterial UTI
Eoisinophilia - allergic tubulointerstitial nephritis
Granular casts - active renal disease
Blood - glomerulonephritis
Renal US - excludes obstruction, see kidney size!
CT - useful to diagnose retroperitoneal fibrosis and other causes of obstruction
Biopsy
Cystoscopy
ECG - hyperkalaemia
Tx CKD
Irreversible so aim is to prevent progression and symptom control!
If eGFR < 30 OR A:C > 70 = stage 4. Refer to nephrology
Lifestyle changes!
Treat underlying cause!
HTN - treat w ABCD etc
Oedema - fluid and sodium restriction, loop diuretic
DM - metform etc
CVD - aspirin, atorvastatin (statins if GFR < 60)
If all else fails - Renal replacement therapy (haemo/peritoneal dialysis, kidney replacement, haemofiltration)
Describe the stages of CKD
Stage 1 - eGFR ≥ 90 (mild damage, kidneys work as normal)
Stage 2 - eGFR 60 - 89 (mild damage, kidneys still work well)
Stage 3a - eGFR 45 - 59 (mild-mod damage, kidneys don’t work as well as they should)
Stage 3b - eGFR 30 - 44 (Mod-severe damage, kidneys don’t work as well as they should)
Stage 4 - eGFR 15 - 29 (Severe damage, close to not working at all)
Stage 5 - eGFR is less than 15! (close to not working at all or have failed, most severe damage)
What are some indications for dialysis?
Symptomatic uraemic - pericarditis or tamponade
Hyperkalaemia - when not controlled by conservative means
Metabolic acidosis
Fluid overload - resistant to diuretics
Comps CKD
Hyperkalaemia
Osteoporosis !
Vit D def
Anaemia
Metabolic acidosis
Pruritus - bc nitrogenous waste products of urea
Pericarditis
HTN
Quick!
Loin pain, Fever, Pyuria
What is it?
Pyelonephritis
Ix ALL UTIs
1st line - Urine dipstick
Will be +leucocytes, + nitrites, +haematuria
GS!!! Midstream microscopy, culture and sensitivity
Pathophysiology Benign Prostate Hyperplasia
Benign proliferation of transitional zone of prostate!
After 30 - men produce 1% less testosterone every year but 5a-reductase increases
∴ ↑ dihydrotestosterone levels
∴ prostate cell hypertrophy
As prostate grows, can squeeze/block bladder
∴ urine retention
∴ bladder dilation and hypertrophy
∴ urine stasis
∴ bacteria
∴ UTI !
Cause BPH
Dihydrotestosterone
RF BPH
Age
FHx
Heart disease
Obesity
DM
What is protective against BPH?
Castration!
Signs / Symptoms BPH
STORAGE
Frequency ↑
Urgency
Nocturia
Urgency incontinence
VOIDING - SHIPP
Straining
Hesitancy
Incomplete emptying
Poor/intermittent stream
Post-micturition dribbling
–
Bladder stones
Acute urinary retention
UTIs
Red flags for prostate cancer
Dysuria - painful/difficult urination
Haematuria
Painless haematuria
What are you instantly assuming it is?
Malignancy
Until proven otherwise
DDx BPH
Overactive bladder syndrome!
Bladder tumour
Bladder stones
Trauma
Prostate/Bladder cancer
UTI
Prostatitis
Ix BPH
International prostate symptom score (IPSS)
Digital rectal exam - smooth, enlarged prostate
PSA - may be raised
Urine dipstick
Biopsy
Abdo exam = enlarged bladder
To exclude renal damage - U&E and renal US
Also to rule out obstruction - US
Tx BPH
Lifestyle advice - avoid caffeine and alcohol
Void twice in a row to aid emptying
1st line - oral tamsulosin
2nd line - oral finasteride, dutasteride
Surgery - GS!
Trans-urethral resection of prostate (TURP)
or Trans-urethral incision of prostate (less destruction, best for small prostates)
What are some indications BPH should be treated with surgery?
RUSHES
Retention
UTIs
Stones
Haematuria (resistant to 5-alpha reductase-inhibitors i.e. FInasteride)
Elevated creatinine
Symptom deterioration
Comps TURP
Risk of ED
Comps BPH
Bladder calculi
UTI
Haematuria
Acute retention
Causes UTI
KEEPS
Klebsiella
E.Coli
Enterobacter
Proteus / Psuedomonas aeruginosa
Staph spp
What is Klebsiella often assoc with?
Hospitals
Catheters
Which KEEPS bacteria for UTIs is most common?
E.Coli !
What is Proteus assoc with?
Renal stones
What is Pseudomonas aeruginosa assoc w?
Recurrent UTIs
A young, sexually active female has a UTI. Which bacteria is it most likely to be?
Staphylococcus spp
Name Lower UTIs
Cystitis
Prostatitis
Urethritis
Epidydymo-orchiditis
Name Upper UTIs
Pyelonephritis
What causes a UTI to be complicated?
Pregnancy
Males
Catheterised patients
Children
Recurrent or Persistent infection
Immunocomp
If acquired in hospital (Nosocomial)
Urosepsis
Signs / Symptoms Lower UTI
HD FUSS
Haematuria
Dysuria
Frequency
Urgency
Suprapubic pain
Smelly urine
Signs / Symptoms Upper UTI
Loin/Abdo pain
Tenderness
N+V
Fever
Costovertebral angle pain
Why do you do midstream urine sample?
Bc first sample of urine has first shedding of epithelial cells
Want to void bacteria away to get fresh part
Why might you get a urine sample first thing in the morning?
Because bacilli accumulate in urine and after a period of dehydration, you will tend to get the highest conc
Signs / Symptoms Pyelonephritis
TRIAD OF : Loin pain, fever, pyuria
Usually unilateral pain
+
Back pain
Headaches
N+V
Rigors
Costovertebral angle pain
Assoc cystitis symptoms
What is Pyelonephritis?
Infection of renal parenchyma and soft tissues of renal pelvis and upper ureter
Route of infection for Pyelonephritis
Infection usually bc E.Coli (UPEC)
Usually via ascending transurethral route
BUT can be via bloodstream or lymphatics (L = rare)
–
Haematogenous - Aureus, Candida
DDx Pyelonephritis
Diverticulitis
Abdo aortic aneurysm
Kidney stones
Cystitis
Prostatitis
Tx Pyelonephritis
Hydration / Fluid replacement
Analgesia!
Co-amoxiclav for 7 days / Trimethoprim for 14 days
+/- Gentamicin if severe
IF PREGNANT, cefalexin for 7 days
IV if severe
Drain obstructed kidney
Who does Cystitis occur in?
Children
Females
Pregnant
Catheterised
Why are women more susceptible to UTIs?
Shorter urethra
Short proximity to anus - allows bacteria transfer
Signs / Symptoms Cystitis
HD FUSS
Haematuria
Dysuria
Frequency
Urgency
Suprapubic pain
Smelly urine
+ Incontinence
+ Confusion in elderly
What drugs are Nephrotoxic?
ACEi
ARBs
NSAIDs
Digoxin
Lithium
What is cystitis?
Urinary infection of the bladder
Causes Cystitis
KEEPS
Mostly E.Coli
Tx Cystitis
1st line - Nitrofurantoin or Trimethoprim
If pregnant! Trimethoprim CANNOT be used in 1st trimester and Nitrofurantoin CANNOT be used in 3rd trimer
∴ use cefalexin (or amoxicillin) instead
2nd line - Ciprofloxacin or co-amoxiclav
What is Prostatitis?
Infection and inflammation of prostate gland
Causes Prostatitis
Acute - Strep. Faecalis, E.Coli, Chlamydia
Chronic :
Bacterial - Strep. Faecalis, E. Coli, Chlamydia
Non-Bacterial - Elevated prostatic pressure, pelvic flood myalgia
RF Prostatitis
STI
UTI
Indwelling catheter
Post-biopsy
Age ↑
Signs / Symptoms Prostatitis
ACUTE :
Systemic symptoms
Fevers, rigors, malaise
Painful ejaculation
Pelvic pain
HD FUSS
CHRONIC :
Acute symptoms > 3 months
Recurrent UTIs
DDx Prostatitis
Cystitis
BPH
Calculi
Prostatic abscess
Malignancy
Ix Prostatitis
the normal PLUS
DRE - prostate = tender, hard from calcification
Blood cultures
STI screen - esp chlamydia
Trans-urethral US scan (TRUSS)
Tx Prostatitis
ACUTE :
1st line - IV gentamycin + IV co-amoxiclav
2nd line - Trimethoprim
TRUSS abscess drainage if necessary
4-6 weeks quinolone etc once well
–
CHRONIC :
4 - 6 weeks of quinolone e.g. ciprofloxacin
+/- alpha-blocker (tamsulosin)
Comps Prostatitis
Urinary retention
What is urethritis?
Urethral inflammation
Causes of Urethritis
GONOCOCCAL - Neisseria gonorrhoea
NON-GONOCOCCAL -
Chlamydia MC !
Mycoplasma genitalium
Trichomonas vaginalis
NON-INFECTIVE -
Trauma
Urethral stricture
Irritation
Urinary calculi
RF Urethritis
Sexually active
Unprotected sex
Male 2 Male sex
Signs / Symptoms Urethritis
May be asymptomatic
Systemic Sx - malaise, fatigue etc
Dysuria
Discharge, blood, pus
Urethral pain
Penile discomfort
Skin lesions
DDx Urethritis
Candida balanitis
Epididymitis
Cystitis
Acute prostatitis
Urethral malignancy
Ix Urethritis
Normal UTI Ix
PLUS
Nucleic Acid Amplification Test (NAAT)
high spec, high sens
F - self-collected vaginal swab, endo-cervical swab, first void urine
M - first void urine
Urine dipstick - to exclude UTI (bc primarily a SEXUALLY ACQ DISEASE)
Urethral smear
Tx Urethritis
Chlamydia :
PO azithromycin or 1week doxycycline PO
IF PREGNANT - PO erythromycin (14days) or PO azithromycin
Gonorrhoea
IM ceftriaxone w/ PO azithromycin
Partner notification
–
Patient ed
Contact tracing
What do you need to keep in mind with urethritis?
Reactive arthritis
- can’t see, can’t pee, can’t climb a tree
When is Epididymo-Orchitis most common?
15 - 30 years
> 60 years
Causes Epididymo-Orchitis
STIs :
< 35 years
Chlamydia trachomatis
Neisseria gonorrhoea
> 35 years
KEEPS
–
Mumps
Trauma
Elderly - usually catheter related
Signs / Symptoms Epididymo-Orchitis
Scrotal pain and swelling! - subacute onset, unilateral
Tenderness
Sweats/fevers
If STI cause : Urethritis, Urethral discharge
If Mumps cause : Headache, fever, unilateral or bilateral parotid swelling
Ix Epididymo-Orchitis
Normal UTI Ix
PLUS
Nucleic Acid Amplification Test (NAAT)
high spec, high sens
F - self-collected vaginal swab, endo-cervical swab, first void urine
M - first void urine
Urine dipstick - to exclude UTI (bc primarily a SEXUALLY ACQ DISEASE)
Urethral smear
Quick!
Genital ulcer, what is the disease?
ANY GENITAL ULCER IS SYPHILIS UNTIL PROVEN OTHERWISE
Quick!
Testicular lump, what is it?
Cancer until proven otherwise
Quick!
Acute and tender lump, what is it?
Testicular torsion until proven otherwise
Big 3 Qs to ask about scrotal masses
- Can you get above it?
- Is it separate from testis?
- Cystic or solid?
Scrotal mass : Cannot get above
What is it?
Inguinoscrotal hernia
OR
Proximally extending hydrocele
Scrotal mass : Separate AND cystic
What is it?
Epididymal cyst
Scrotal mass : Separate AND solid
What is it?
Epididymitis
OR
Varicocele
Scrotal mass : Testicular AND cystic
What is it?
Hydrocele
Scrotal mass : Testicular AND solid
What is it?
Tumour, haematocele
Describe an Epididymal cyst
Smooth, extratesticular, spherical cyst in head of epididymis
What does an epididymal cyst contain?
Clear and milky (spermatocele) fluid
Signs / Symptoms Epididymal cyst
Can be painful once large
Lump - often multiple and bilateral
Well defined
Will transluminate
Testis palpable SEPARATE from cyst
How do differentiate between epididymal cyst and spermatocele?
You cannot clinically differentiate
Only way is to aspirate bc sperm present in fluid if spermatocele
Ix Epididymal Cyst
Scrotal US
Transilumination - to eliminate hydrocele
What is a Hydrocele?
Abnormal collection of fluid within tunica vaginalis
aka fluid surrounds testes
Describe a 1º Hydrocele
More common and larger
Usually in young men
Assoc w/ patent processus vaginalis - which usually resolves in 1st year of life
What can a 2º Hydrocele be secondary to?
Testis tumour
Trauma
Infection
TB
Testicular torsion
Generalised oedema
Signs / Symptoms Hydrocele
Unless infected, shouldn’t be painful!
Non-tender, smooth, cystic swelling
Testis usually palpable but if large, might be difficult
Will transluminate
DDx Hydrocele
Testicular torsion
Strangulated hernia
Ix Hydrocele
Scrotal US
Serum AFP and HCG - exclude malignancy
FBC - to check for infection
Transillumination
Tx Hydrocele
Resolve spontaneously
Esp in infancy - resolves by 2 years
Therapeutic aspiration or surgical removal
What is a varicocele?
Abnormal dilation of testicular veins in pampiniform venomous plexus
Pathophysiology Varicocele
Left renal vein invades L testicular vein
∴ compression
∴ impaired venous drainage (venous reflux)
∴ ↑ venous pressure
∴ vein dilation
∴ causes varicocele
Signs / Symptoms Varicocele
Dull ache
Scrotal heaviness
“Bag of worms” - distended scrotal blood vessels
Ix Varicocele
Venography
Colour doppler US - to see blood flow
Tx Varicocele
Surgery !
If pain, infertility or testicular atrophy
What is Haemotocele?
Blood in tunica vaginalis
Cause Haemotocele
Trauma
Tx Haematocele
Aspiration or surgery
In testicular torsion, which cells are the most susceptible to ischaemia?
Germ cells
What age is testicular torsion most common?
11-30 years
What side is more commonly affected in testicular torsion?
Left
Causes Testicular Torsion
Teens/Neonates :
Bell-clapper deformity
When testis isn’t fixed fully to scrotum ∴ can move freely on axis
Adults - testicular malignancy
RF Testicular Torsion
FHx - Genetics
Signs / Symptoms Testicular Torsion
Sudden onset testicular pain!
Makes walking difficult
Comes on during sports and physical activity
Inflamed & tender testicle
Abdo pain
N+V
Unilateral pain
High riding testicle
Absent cremasteric reflex
NEG Prehn’s sign
DDx Testicular torsion
Epididymo-Orchitis
Tumour, trauma, acute hydrocele
Idiopathic scrotal oedema
Ix Testicular Torsion
Emergency!!!!
QUICK!!
Don’t delay surgical exploration!
Doppler US - shows decreased blood flow!!
Urinalysis - to exclude infection and epididymis
Tx Testicular Torsion
Surgery within 6 hours!!!!
Salvage rate = 90-100%
but if > 24 hours = 1-10% !
Orchidectomy and bilateral fixation
What is a positive Prehn’s sign?
When lifting testicle lessens pain / provides relief
When is Prehn’s sign POSITIVE?
Epididymitis
NEG IN TESTICULAR TORSION
Typical case of Post-Streptococcus Glomerulonephritis
Child had a strep infection (pharyngitis, cellulitis, tonsilitis)
1-3 weeks later, they present with haematuria, oliguria, proteinuria etc
Cause Post-Strep Glomerulonephritis
Lancefield Group A beta haemolytic streptococcus
e.g. STREP PYOGENS
Pathophysiology Post-Strep Glomerulonephritis
Bacterial antigens are deposited in glomerulus
TYPE III HYPERSENSITIVITY REACTION
Ix Post-Strep Glomerulonephritis
Urine dipstick and microscopy - RED CLAST CELLS
Proteinuria, ↓ GFR etc
Combined with history of previous Strep infection
Cause IgA Nephropathy
Abnormal IgA1
Pathophysiology IgA Nephropathy
Abnormal IgA is deposited in the mesangium
Kidney is then attacked by anti-glycan antibodies
∴ complement pathway is activated
Type III HYPERSENSITIVTY REACTION !!
(inflam occurs at site of deposition, not site of formation)
Signs / Symptoms IgA Nephropathy
Usually in childhood, after a GI or resp infection
Nephritis Sx
+ Uraemia - anorexia, rash, lethargy etc
How does Henloch-Schonlein Purpura present?
Similar to IgA Nephropathy
But also purpuric rash on legs, joint pain
Ix IgA Nephropathy
History - to find cause
Measure eGFR, proteinuria, serum urea etc
GS!!! Biopsy!!!
Diffuse mesangial IgA deposits
Sub-endothelial and sub-epithelial deposits
Light microscopy - mesangial proliferation
Urine dipstick
Tx IgA Nephropathy
Supportive !!
Control BP (ACEi, ARBs etc)
lower cholesterol
etc
Immunosuppression (to avoid immune complexes forming)
Induction = steroids + cyclophosphamide
Remission = steroids + azathioprine
What is IgA Nephropathy also known as?
Berger disease
What is Goodpasture’s Syndrome?
Autoimmune condition that attacks the type IV collagen in the basement membrane of lungs and kidney
What type of hypersensitivity reaction is Goodpasture’s syndrome?
Type 2 - anti GBM antibodies
Signs / Symptoms Goodpasture’s syndrome
HAEMOPTYSIS + HAEMATURIA
SOB + some resp signs !
Nephritic symptoms
Rapid progressive kidney failure
Ix Goodpasture’s Syndrome
GS!! - anti-GBM and renal biopsy
Tx Goodpasture’s syndrome
Plasma exchange - to remove antibodies
Steroids
Cyclophosphamide
What is testicular appendage torsion?
NOT a medical emergency (unlike appendage torsion)
Twisting of the appendix of the testicle i think idk dont quote me on this look it up a bit more pls
Types of Prostate Cancer
Adenocarcinomas - MC! arise from periph zone
Transitional cell carcinomas - arise from transitional zone
Small cell prostate cancer
How can prostate cancer spread?
Local - to seminal vesicles, bladder, rectum
Via Lymph
Haematogenously - to bone, brain, liver, lung
CAN METASTASISE - to bone, lung, adjacent structures
RF Prostate Cancer
Age
Obesity
FHx - BRCA1, BRCA2 (HOXB13 predisposition gene)
High fat, low fibre diet
↑ Testosterone
Black skin tone
Screening Prostate Cancer
Prostate specific antigen
But not always reliable
Signs / Symptoms Prostate Cancer
Asymptomatic at first
LUTS symptoms - same as BPH
FUUN SHIPP
Haematuria
Cancer B Sx - weight loss, anorexia, night sweats
Anaemia
Bone pain (metastases)
Why is prostate cancer usually asymptomatic at first?
Bc most prostate malignancies arise from peripheral zone
Which is far from urethra
∴ can grow large before starts to present
DDx Prostate cancer
BPH
Bladder cancer
Prostatitis
Ix Prostate Cancer
DRE - hard, irregular
PSA - non specific
Trans-urethral US scan (TRUSS)
Prostate biopsy! - Gleason grading
Imaging
Bone Scan
TMN staging!
Describe how one would use Gleason grading
Histological grades for 2 most common patterns (1-5)
Then add up together
Higher score = ↑ aggressive
Generally, 6 = low grade, 7 = mid grade
8 - 10 = high grade, v aggressive cancer
Describe TNM staging for prostate cancer
T1 - no palpable tumour on DRE
T2 - palpable tumour but confined to prostate
T3 - palpable tumour that extends past prostate
(There is T3a and T3b, also T4 = metastases)
N stage - Nodes -> MRI scan, CT scan
M stage - Metastases -> bone scan
Tx Prostate Cancer
If low risk, watchful waiting
Localised radical Tx = radical prostatectomy or radical radiotherapy
Hormone therapy - slows tumour growth
> GnRH agonist e.g. SC Goserelin, Leuprorelin
> Androgen receptor blockers e.g. Bicalutamide
If metastatic -
Bilateral surgical orchidectomy (castration) or palliative care :(
Treat hypercalcaemia with diuretics
Bisphophonates - zolendronic acid
Why are hormone therapies esp used in prostate cancer?
Bc prostate malignancies are the malignancy most sensitive to hormone therapy
How does Wilm’s tumour present?
IN CHILDREN
Abdo mass
Haematuria
What is the major abdo malignancy in children?
Wilm’s tumour
Wilm’s tumour is a malignancy of ?
Renal tubules
and mesenchymal cells
When might PSA be raised?
BMI < 25
Black Africans
Taller men
Recent ejaculation
Recent rectal examination
Prostatitis
BPH
Prostate cancer
UTI
Indications for dialysis
AEIOU
Acidosis - pH < 7.2 OR bicarbonate < 10mmol
Electrolyte imbalance - persistent hyperkalaemia 7mmol/L
Intoxication - BLAST (Barbiturates, Lithium, Alcohol, Salicylates, Theophylline)
Oedema (refractory pulmonary oedema)
Uraemia - encephalopathy or pericarditis, urea > 40
Would the eGFR increase or decrease with Post-Strep glomerulonephritis? Why?
DECREASE
bc deposition of immune complexes ∴ ↓ ability to filter toxins
∴ ↓ eGFR
What drugs should be stopped in AKI?
Stop the DAMN drugs
Diuretics & digoxin
ACEi / ARBs
Metformin
NSAIDs
Big diff between IgA Nephropathy and Post-Strep
TIMELINE
Post-strep is 1-2 weeks later
IgA is days
i think?
Quick!
Patho of NephrOtic syndrome?
Usually issue w filtration barrier - podocytes
∴ protein leaks into urine
Causes Nephrotic Syndrome
MFM
Minimal change disease
Focal Segmental Glomerulosclerosis
*M**embranous Nephropathy
General presentation of Nephrotic syndrome
PROTEINURIA > 3.5g/day
Hypoalbuminaemia
Oedema
Hyperlipidaemia
General presentation of Nephritic syndrome
HAEMATURIA
↓GFR
Oliguria
Proteinuria < 2g/day
Oedema
HTN
Pathophysiology Minimal Change disease
Cytokines attack foot processes of podocytes
∴ Shrinkage/Blunting of podocytes
∴ Protein leakage
What Nephrotic syndrome is most common in children?
MINIMAL CHANGE DISEASE
Ix Minimal Change Disease
Renal biopsy
Electron microscopy
Tx Minimal Change Disease
Corticosteroids
+/- Cyclophosphamide or Cyclosporine (if freq recurring)
Pathophysiology Focal Segmental Glomerulosclerosis
Podocytes are damaged (how?? no clue)
∴ proteins + lipids go into urine
Overtime, protein + lipids are trapped in glomerulus
∴ Hyalinosis (glassy appearance on histology)
∴ sclerosis
RF Focal Segmental Glomerulosclerosis
African-American!!!
2º Cause Focal Segmental Glomerulosclerosis
SCD
HIV
Heroin abuse
Kidney hypoperfusion
Ix Focal Segmental Glomerulosclerosis
Renal biopsy & Histology - hyalinosis, effacement of foot processes & segmental sclerosis
Immunofluorescence - non-spec deposits of IgM and complement
Tx Focal Segmental Glomerulosclerosis
Steroids
Pathophysiology Membranous Glomerulonephritis
IgG deposition in sub-epithelial surgace
∴ thickening of glomerular capillary wall
∴ damaged glomerulus
∴ protein leaks out
1º cause of Membranous Glomerulonephritis
PLA2R antigen targets glomerular podocyte membrane
2º Membranous Glomerulonephritis
Autoimmune conditions
Viruses
Drugs
Tumours
Ix Membranous Glomerulonephritis
Renal biopsy
Electron microscopy - thickened capillaries and GBM (spike and dome pattern!)
Effacement of foot processes
PLA2R antigen
Tx Membranous Glomerulonephritis
Supportive - oedema, HTN, proteinuria etc
Immunosuppression - steroids, cyclophosphamide
RAAS blockade?
Anti-Coag
Signs / Symptoms SLE Nephropathy
Rash
Arthralgia
Kidney failure
Pericarditis
Pneumonia
Ix SLE Nephropathy
Anti-Nucelar antibody pos
Double stranded DNA pos
Low complement C3 + C4
Tx SLE Nephropathy
Immunosuppresion -
Steroids
Cyclophosphamide
Rituximab
