Renal & GU Flashcards
1
Q
What is benign prostatic hyperplasia?
A
An increase in epithelial and stromal cell numbers in the periurethral area of the prostate.
This may be due to an increase in cell number, decrease in apoptosis, or both.
2
Q
What is the difference between benign prostatic hyperplasia and benign prostatic enlargement?
A
Hyperplasia is from the histological findings and enlargement is from the DRE findings.
3
Q
What is bladder outflow obstruction?
A
Urodynamic proven obstruction of the lower urinary tract.
4
Q
Define what is meant by lower urinary tract symptoms.
A
Constellation of symptoms, neither gender nor disease specific.
5
Q
Briefly describe the two components of the pathophysiology of benign prostatic enlargement.
A
- Alpha1 adrenoreceptors mediate prostatic smooth muscle contraction
- Increased volume of prostate causes anatomical obstruction
6
Q
How are androgens involved in benign prostatic hyperplasia?
A
They do not cause BPE but are required to develop it.
7
Q
Give a system used to assess LUTS in men.
A
International prostate symptom score (IPSS)
8
Q
What are the storage LUTS?
A
- Frequency
- Nocturia
- Urgency
- Urgency incontinence
9
Q
How often is it normal to go to the toilet at night?
A
Never
10
Q
Give the voiding LUTS.
A
- Hesitancy
- Straining
- Poor/intermittent stream
- Incomplete emptying
11
Q
Give a post-micturition LUTS.
A
Dribbling
12
Q
Give two red flag LUTS.
A
- Haematuria
- Dysuria
13
Q
Give five examinations that should be carried out in patients with LUTS.
A
- General examination (fitness for surgery)
- Abdominal and external genitalia examination
- Digital rectal examination
- Focussed neurological examination
- Urinalysis
14
Q
What is the normal urinary flow rate for:
A) <40yrs
B) 40-60yrs
C) >60yrs
A
A) >21ml/s
B) >18ml/s
C) >13ml/s
15
Q
What is the normal urinary residual volume?
A
<12ml
16
Q
Give nine investigations that can be carried out in patients with LUTS.
A
- Flow rates
- Residual volume
- Frequency volume chart
- Renal biochemistry
- Imaging
- PSA
- Trans-rectal ultrasound (TRUSS)
- Flexible cystoscopy
- Urodynamics
17
Q
Briefly describe a urodynamic investigation.
A
Insert catheter and fill bladder, then look at how the detrusor muscle reacts.
18
Q
What is the main aim of treatment in LUTS?
A
Improve symptoms and quality of life.
19
Q
Give 4 treatment options for LUTS.
A
- Watchful waiting
- Alpha adrenergic antagonists
- 5-alpha-reductase inhibitors
- Surgery
20
Q
Give two examples of alpha adrenergic antagonists.
A
- Alfuzasin
- Tamsulosin
21
Q
How do alpha adrenergic antagonists work?
A
They reduce the muscle tone of the prostatic smooth muscle.
22
Q
Give three side effects of tamsulosin.
A
- Postural hypotension
- Retrograde ejaculation
- Erectile dysfunction
23
Q
How do 5-alpha-reductase inhibitors work?
A
Inhibit conversion of testosterone to dihydrotestosterone.
24
Q
Give two examples of 5-alpha-reductase inhibitors.
A
- Finasteride
- Dutasteride
25
Give a side effect of 5-alpha-reductase inhibitors.
Erectile dysfunction
26
Why is combination pharmacological therapy usually used in BPE?
5-alpha-reductase inhibitors prevent symptoms worsening and further enlargement, but take a long time to reduce symptoms.
27
What are the indications for surgery in BPE?
RUSHES
- Retention
- UTIs
- Stones
- Haematuria
- Elevated creatinine
- Symptom deterioration
28
Give seven surgical treatment options for BPE.
- Bladder neck incision
- Trans-urethral resection of prostate (TURP)
- Bipolar
- Greenlight laser
- Thullium laser
- Holmium laser
- Millins retro-pubic prostatectomy
29
What causes TUR syndrome?
Pure water is used to flush the urethra in TURP, and when this is absorbed by the body it causes hyponatraemia, cerebral oedema, and visual disturbances.
30
Give nine possible complications of TURP.
- TUR syndrome
- Sepsis
- Haemorrhage
- Clot retention
- Retrograde ejaculation
- Erectile dysfunction
- Urethral stricture
- Bladder neck stenosis
- Urinary incontinence
31
Give seven complications of BPE.
- Symptom progression
- Infections
- Stones
- Haematuria
- Acute retention
- Chronic retention
- Interactive obstructive uropathy
32
Describe acute urinary retention.
Painful retention of urine, typically 600ml-1L.
33
Describe chronic urine retention.
Usually painless incomplete bladder emptying.
34
What can interactive obstructive uropathy lead to?
Hydronephrosis and renal failure.
35
Describe the parasympathetic innervation of the bladder.
Pelvic nerve from S2/3/4.
| Contracts detrusor muscle and relaxes internal urethral sphincter.
36
Describe the sympathetic innervation of the bladder.
Hypogastric nerve from T10-L2.
| Relaxes detrusor muscle and contracts internal urethral sphincter.
37
Describe the somatic innervation of the bladder.
Pudendal nerve from S2/3/4.
| Voluntarily relaxes external urethral sphincter.
38
Define acute kidney injury.
Rapid reduction in kidney function over hours to days, as measured by serum urea and creatinine, and leading to failure to maintain fluid, electrolyte, and acid-base homeostasis.
39
Give some risk factors for acute kidney injury.
- Age >75yrs
- Chronic kidney disease
- Cardiac failure
- Peripheral vascular disease
- Chronic liver disease
- Diabetes
- Drugs (especially newly started)
- Sepsis
- Poor fluid intake/increased losses
- History of urinary symptoms
40
What are the pre-renal causes of acute kidney injury?
- Renal hypoperfusion
- Hypotension
- Hypovolaemia
- Sepsis
- Renal artery stenosis
- Ischameia
41
What is the most common cause of renal AKI?
Acute tubular necrosis.
42
Give six causes of acute tubular necrosis.
- Nephrotoxins
- Radiological contrast
- Myoglobinuria from rhabdomyolysis
- Crystal damage
- Myeloma
- Hypercalcaemia
43
Give four causes of glomerular AKI.
- Autoimmune
- Drugs
- Infections
- Primary glomerulonephritides
44
Give two causes of interstitial AKI.
- Drugs
| - Infiltration
45
Give four vascular causes of intrarenal AKI.
- Vasculitis
- Malignant hypertension
- Thrombus/cholesterol emboli
- Large vessel occlusion
46
Give three general categories of post-renal causes of AKI.
- Luminal obstruction
- Mural
- Extrinsic compression
47
Give 3 causes of luminal obstructive causes of AKI.
- Stones
- Clots
- Sloughed papillae
48
Give three causes of mural causes of AKI.
- Malignancy
- BPH
- Strictures
49
Give two causes of extrinsic compression, which can cause AKI.
- Malignancy
| - Retroperitoneal fibrosis
50
Give the three possible diagnostic criteria for AKI.
- Rise in creatinine >26μmol/L in 48hrs
- Rise in creatinine >1.5x baseline (best figure in last 3 months)
- Urine output <0.5ml/Kg/hr for >6 consecutive hours
51
Describe stage 1 AKI according to the KDIGO staging system.
- Creatinine increase >26μmol/L in 48hrs or increase >1.5x baseline
- Urine output <0.5ml/Kg/hr for >6 consecutive hrs
52
Describe stage 2 AKI according to the KDIGO staging system.
- Creatinine increase 2-2.9x baseline
| - Urine output <0.5ml/Kg/hr for >12hrs
53
Describe stage 3 AKI according to the KDIGO staging system.
- Creatinine increase >3x baseline or >354μmol/L or commenced RRT
- Urine output <0.3ml/Kg/hr for >24hr or anuria for 12hr
54
Give four investigations that may help to assess AKI.
- Urine dip
- Blood tests (creatinine, urea, potassium)
- ABG for acid-base
- Renal USS
55
Give five general management principles for AKI.
- Assess volume status
- Aim for euvolaemia
- Stop nephrotoxic drugs
- Monitoring
- Nutrition
56
What does it mean if a patient in AKI is described as ‘wet’?
They are congested from heart failure.
57
What does it mean if an AKI patient is described as ‘dry’?
They are dehydrated.
58
Give two ways that pre-renal underlying causes of AKI are treated.
- Correct volume depletion
| - Treat sepsis
59
How are renal causes of AKI treated?
Refer early to nephrology
60
Give two management strategies for post-renal causes of AKI.
- Catheterize
| - Urology referral if obstruction
61
Give a major complication of AKI.
Hyperkalaemia
62
How is urgent hyperkalaemia treated?
- Insulin + dextrose
- Calcium gluconate
- Can also give IV fluid, salbutamol, and calcium resonium
63
Why is calcium gluconate given in urgent hyperkalaemia?
For cardiac protection
64
How does insulin + dextrose treat hyperkalaemia?
They stimulate cellular potassium uptake.
65
Give four complications of AKI.
- Hyperkalaemia
- Pulmonary oedema
- Uraemia
- Acidaemia
66
How can pulmonary oedema be treated in AKI?
- High flow oxygen
- Venous vasodilator
- Furosemide
67
Give two complications of uraemia.
- Pericarditis
| - Encephalopathy
68
Give a treatment that may be required for uraemia.
May require dialysis
69
How might acidaemia be treated in AKI?
May require dialysis, but consider sodium bicarbonate.
70
Give two types of renal replacement therapy.
- Haemodialysis
| - Haemofiltration
71
Give five drug overdoses which may require dialysis in AKI.
BLAST
- Barbiturate
- Lithium
- Alcohol-ethylene glycol
- Salicylate
- Theophylline
72
Give three functions of the urinary tract.
- Collect urine produced continuously by the kidneys
- Store collected urine safely
- Expel urine when socially acceptable
73
What vertebral levels do the kidneys lie between?
T11-L3
74
At which vertebral level does the renal artery branch off the aorta?
L1
75
How is reflux of urine from the bladder to the ureters prevented?
Valvular mechanism at the vesicoureteric junction.
76
Describe the sensory innervation of the bladder.
The afferent pelvic nerve carries signals from the detrusor muscle.
77
Describe the neural pathway which controls micturition.
- Afferent sensory pelvic nerve
- Pontine micturition centre
- Periaqueductal grey and cortex
- Back to pontine micturition centre
- To sacral micturition centre
78
What reflex is activated if it is inappropriate to void urine?
Guarding reflex
79
What reflex is activated if it is appropriate to void urine?
Micturition reflex
80
What is the capacity of a normal adult bladder?
400-500ml
81
At what volume is the first sensation of the bladder filling felt?
100-200ml
82
What actions does the detrusor muscle take as the bladder fills?
Receptive relaxation, to keep the pressure in the bladder low.
83
Describe the micturition reflex in children and people with a brain injury.
- Afferent pelvic nerve sends fast signals to the sacral micturition centre
- Pelvic parasympathetic nerve activated
- Detrusor muscle contracts
- Pudendal nerve inhibited
- External sphincter relaxes
84
Describe the micturition guarding reflex.
- Afferent signals from pelvic nerve received by PMC and PAG
- Signals transmitted to higher cortical centres
- Sympathetic nerve stimulation results in detrusor relaxation
- Pudendal nerve stimulation results in contraction of external urethral sphincter
85
Which nucleus is involved in the micturition guarding reflex?
Onuf’s nucleus
86
In which gender is incontinence more common?
Women
87
Why is urinary incontinence more common in women?
The bladder neck in females doesn’t act as a proper sphincter. It does in men to prevent retrograde ejaculation.
88
What percentage of the population over the age of 65yrs experience incontinence?
48%
89
Define urgency incontinence.
Urgency with frequency, with or without nocturia, when appearing in the absence of local pathology.
90
Describe the difference between wet and dry urgency incontinence.
Wet is when they can’t get to the toilet on time, dry is when there is urgency but they can get to the toilet.
91
What may be seen on urodynamics in urgency incontinence?
Detrusor overactivity
92
Give three behavioural techniques used to control urgency incontinence.
- Reduce caffeine
- Reduce alcohol
- Bladder drills/training
93
Give two types of pharmacological therapy used for urgency incontinence.
- Anti-muscarinic agents
| - B3 agonists
94
Give a side effect of anti-muscarinic agonists used to treat urgency incontinence.
Dry mouth
95
How does botox treat urgency incontinence?
Blocks neurotransmitter ACh junction.
96
How long does botox treatment for urgency incontinence last?
6-9months
97
Give a side effect of botox being used to treat urgency incontinence.
Incomplete bladder emptying and retention
98
Describe how sacral neuromodulation can be used to treat urgency incontinence.
Insertion of an electrode into the S3 nerve root modulates afferent signals from the bladder.
99
Describe the surgery that can be carried out to treat urgency incontinence.
Augmentation cystoscopy (section of ileum is used to increase bladder size).
100
What is stress incontinence?
Incontinence related to coughing or straining.
101
Give three causes of stress incontinence in women.
- Birth trauma
- Neurogenic
- Congenital
102
Give two ways that birth trauma can cause stress incontinence.
- Denervation of pelvic floor and urethral sphincter
| - Weakening of fascial support of bladder and urethra
103
Give two possible treatment options for stress incontinence in women.
- Pelvic floor physiotherapy
| - Surgery
104
Give four surgical treatments for stress incontinence in women.
- Sling
- Colposuspension
- Bulking agents
- Artificial sphincter
105
Give two causes of stress incontinence in men.
- Neurogenic
| - Iatrogenic (following prostatectomy)
106
Give two treatment options for stress incontinence in men.
- Artificial sphincter
| - Male sling
107
What causes continuous incontinence?
Fistula
108
Give three features of spastic (supra-conal) spinal cord injury urinary incontinence.
- Reflexive bladder contractions
- Detrusor sphincter dyssenergia
- Poorly sustained bladder contraction (incomplete voiding)
109
What is detrusor sphincter dyssynergia?
When the detrusor and bladder contract at the same time, leading to increased pressure in the bladder.
110
Give three features of flaccid (conus) spinal cord injury.
- Loss of reflex bladder contraction
- Loss of guarding reflex
- Loss of receptive relaxation
111
Give three consequences of flaccid (conus) spinal cord injury.
- Areflexic bladder
- Stress incontinence
- Risk of poor compliance
112
Describe autonomic dysreflexia.
- Occurs if there is a lesion above T6
- Noxious stimulus (full bladder) causes overstimulation of sympathetic nervous system
- Results in headache, severe hypertension, and flushing
113
Give two possible treatment options for reflexive bladder.
- Harness reflexes to empty bladder into continence device
| - Suppress reflexes converting bladder to flaccid type, then empty regularly
114
Give two types of bladder emptying that are alternatives to an indwelling catheter.
- Convene drainage (covering over penis so urine enters bag)
| - Supra-pubic catheter
115
Give two possible side effects of a supra-pubic catheter.
- Infections
| - Stones
116
In which zone of the prostate does hypertrophy usually occur?
Transitional zone
117
In which zone of the prostate does cancer usually occur?
Peripheral zone
118
Prostate cancer is the ______ most common cancer overall.
3rd
119
Prostate cancer is the _______ largest cause of cancer death in men and women.
4th
120
Describe and explain the current trends in the incidence of prostate cancer.
Incidence is rising, potentially due to picking up more cases with PSA.
121
Describe the typical age of someone diagnoses with prostate cancer.
- Usually occurs after 40
- Incidence rises with age
- Mean age at diagnosis = 72yrs
122
What is someone’s lifetime risk of a prostate cancer diagnosis?
12-16%
123
Describe the prognosis in most prostate cancers.
Most cases are very slow growing and most will die WITH disease, not FROM it.
124
Give two risk factors for prostate cancer.
- Family history
| - Increased testosterone
125
What is the precursor lesion which can form prostate cancer?
Prostatic intraepithelial neoplasia (PIN)
126
What type/classification of tumour is prostate cancer?
Adenocarcinoma
127
What percentage of prostate cancers are multifocal?
85%
128
Describe the spread of prostate cancer.
Spreads locally through prostate capsule, then metastasises to lymph nodes, bone, and occasionally lung, liver, and brain.
129
Describe the bone metastases in prostate cancer.
Sclerotic
130
Give five things that can help to diagnose prostate cancer.
- LUTS
- DRE
- Biomarkers
- Trans-rectal ultrasound scan
- Prostate biopsy
131
What may be felt on a DRE in prostate cancer?
Hard, irregular prostate
132
Give two serum biomarkers for prostate cancer.
- Prostate specific antigen (PSA)
| - Prostate-specific membrane antigen (PSMA)
133
What is the role of prostate specific antigen in normal physiology?
Liquefies semen
134
Give two urine biomarkers for prostate cancer which are rarely used.
- PCA3
| - Gene fusion products
135
Give six causes of in elevated PSA which are NOT prostate cancer.
- Benign prostatic enlargement
- Urinary tract infection
- Prostatitis
- Trauma
- Recent ejaculation
- Exercise
136
What percentage of people with an elevated PSA will not have cancer?
70%
137
What percentage of people with prostate cancer will have a normal PSA?
6%
138
What PSA score means that prostate cancer is unlikely?
<2.5
139
What PSA score means that there is likely to be metastatic disease?
>20
140
As well as screening and picking up prostate cancer, how else can PSA be used in prostate cancer?
To monitor the response to treatment.
141
How is prostate cancer graded?
Gleason grading
142
Briefly describe how Gleason grading is carried out.
Add the two most common histological gradings together, the higher score the more aggressive.
Scale goes from 2-10.
143
At what Gleason score is the cancer pretty much benign?
<6
144
What are the two general management principles for localised prostate cancer?
- Observation
| - Curative
145
Give three possible curative treatments for localised prostate cancer.
- Surgery
- Radiotherapy
- Adjuvant hormones
146
What surgery is carried out in prostate cancer?
Radical prostatectomy
147
Give two treatment options for locally advanced prostate cancer.
- Surgery
| - Radiotherapy + neoadjuvant hormone therapy
148
Give two treatment options for metastatic prostate cancer.
- Surgical castration
| - Palliative hormone therapy
149
Give two possible benefits of surgical castration in metastatic prostate cancer.
- Reduced pain from bony metastases
| - Prolonged survival
150
What percentage of prostate cancers are androgen-sensitive?
80%
151
Give a surgical type of androgen deprivation therapy for prostate cancer.
Orchidectomy
152
Give three medical types of androgen deprivation therapy for prostate cancer.
- GnRH analogues
- LH antagonists
- Peripheral androgen receptor antagonists
153
How do GnRH analogues result in androgen deprivation?
They downregulate receptors
154
What is the median survival time in metastatic prostate cancer when treated with surgical castration?
2.5yrs
155
Give three issues with screening for prostate cancer using PSA.
- Not specific
- Leads to overdiagnosis
- Leads to overtreatment
156
What is the most common malignancy of the GU tract?
Bladder cancer
157
Describe the age range of people with bladder cancer.
- Incidence rises with age
| - Usually occurs >40yrs
158
Is bladder cancer more common in men or women?
Men
159
What percentage of all cancer deaths are due to bladder cancer?
3%
160
Give eight risk factors for bladder cancer.
- Smoking
- Travel (parasites)
- Exposure carcinogens (occupational rubber and paint)
- Chemo/cyclophosphamide
- Family history
- Paraplegia
- Long term catheters
- Bladder stones
161
Give the two main symptoms/presentations of bladder cancer.
- Painless visible haematuria
| - Irritative voiding/recurrent UTI
162
What type of bladder cancer does irritable voiding/recurrent UTIs suggest?
Carcinoma in situ
163
What percentage of bladder cancer patients have metastases on presentation?
17-20%
164
Give three times when haematuria is significant.
- Visible
- Symptomatic, non-visible without known cause
- Persistent asymptomatic non-visible
165
What is the most common type of bladder cancer?
Transitional cell carcinoma/urothelial cell carcinoma (>90%)
166
What percentage of bladder cancers are squamous cell carcinomas?
5%
167
What usually causes squamous cell carcinoma of the bladder?
Chronic irritation to the bladder
168
What percentage of bladder cancers are adenocarcinomas?
<1%
169
Describe a bladder carcinoma in situ.
Poorly differentiated but confined to the epithelium.
170
What percentage of bladder carcinomas in situ become muscle invasive?
50%
171
What investigations should be carried out in bladder cancer?
- Dipstick test
- Bloods
- Cytology (if available)
- Imaging (USS/CT)
- Flexible cystoscopy
172
What is the main diagnostic test used for bladder cancer?
Biopsy via transurethral resection of bladder tumour (TURBT).
173
Describe how a dipstick test detects blood in the urine.
Detects presence of haemoglobin.
90% sensitive.
Many causes of false positives.
174
When should someone over 45 years old be referred for suspected bladder cancer.
- Unexplained visible haematuria without UTI
OR
- Visible haematuria that persists or recurs after successful treatment of UTI
175
When should someone over 60yrs be referred for suspected bladder cancer?
Unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test.
176
When should a non-urgent referral for bladder cancer be done?
People aged 60 and over with recurrent or persistent unexplained urinary tract infection.
177
Give three infectious differential diagnoses of bladder cancer.
- UTI
- Pyelonephritis
- TB
178
Give a malignancy differential diagnosis of bladder cancer.
Malignancy anywhere in tract
179
Give three ‘stone’ differential diagnoses of bladder cancer.
- Bladder
- Kidney
- Ureteric
180
Give two traumatic differential diagnoses of bladder cancer.
- Penetrating trauma
| - Blunt trauma
181
Give two nephrological differential diagnoses of bladder cancer.
- Diabetes
| - Nephropathy (proteinuria)
182
Describe how anticoagulation affects haematuria.
Does not cause haematuria but can allow it to become apparent.
183
What percentage of bladder cancers are non muscle invasive on presentation?
80%
184
Give three possible treatments for non muscle invasive bladder cancer.
- BCG
- Resection
- Mitomycin C
185
Give three possible treatments for muscle invasive bladder cancer.
- Cystectomy (+ ileal conduit or neobladder)
- Radiotherapy
- +/- chemotherapy
186
What is the 10 year survival rate in bladder cancer?
50%
187
What percentage of non muscle invasive bladder cancers will recur?
70%
188
What percentage of non muscle invasive bladder cancer will progress to muscle invasive?
15%
189
What percentage of cancers does renal cancer account for?
3%
190
What is the typical age of someone with renal cancer?
Usually occurs >30yrs
| Mean age = 55yrs
191
Is renal cancer more common in males or females?
Males
192
What is the 10yr survival rate in renal cancer?
50%
193
Give four risk factors for renal cancer.
- Smoking
- Obesity
- Hypertension
- Dialysis
194
What is the most common type of renal cancer?
Renal cell carcinoma (95%)
195
What percentage of renal cancers are transitional cell carcinomas?
<5%
196
What percentage of renal cancers are picked up incidentally?
66%
197
What percentage of people with renal cancer will have metastases on presentation?
30%
198
What percentage of people with renal cancer will present with paraneoplastic syndromes?
30%
199
What is the classic triad of presentation for renal cancer (which is hardly seen)?
- Haematuria
- Flank pain
- Mass
200
What would you expect blood pressure to be in renal cancer and why?
High due to renin secreiton
201
What would you expect the FBC to show in renal cancer and why?
Polycythaemia due to increased EPO secretion.
202
What may be present in the urine of a patient with renal cancer?
Red blood cells
203
What imaging can be carried out to assess renal cancer?
- USS
| - CT/MRI
204
Describe stage I renal cancer.
- <7cm in largest dimension
| - Limited to kidney
205
Describe stage II renal cancer.
- >7cm in largest dimension
| - Limited to kidney
206
Describe stage III renal cancer.
- Tumour in major veins or adrenal gland
- Regional lymph nodes involved
- Intact Gerota’s fascia
207
Describe stage IV renal cancer.
- Tumour beyond Gerota’s fascia
| - Distant metastases
208
Give four general management options for renal cancer.
- Surveillance
- Surgery
- Ablative therapy
- Systemic therapy
209
Give three surgical options for renal cancer.
- Radical nephrectomy
- Partial nephrectomy
- Lymphadenectomy
210
Give two ablative therapies for renal cancer.
- Cryoabalation
| - Radiofrequency abalation
211
Give two systemic therapies for renal cancer.
- Immunotherapy
| - Targeted therapy
212
Give a sign of a true scrotal mass on palpation.
It is possible to get above it.
213
How can transillumination be used to assess scrotal masses?
Cystic masses can be transilluminated, solid masses cannot.
214
What is the assumed diagnosis (until proven otherwise) in an acutely painful scrotum?
Torsion of testes
215
What is the assumed diagnosis (until proven otherwise) in testicular lump?
Cancer
216
When do epididymal cysts usually occur?
In adulthood
217
What is an epididymal cyst?
A cyst on the epididymis containing clear or milky fluid.
218
What can an epididymal cyst be called if it contains milky fluid?
Spermatocele
219
Where does an epididymal cyst lie in relation to the testes?
Above and behind
220
When should an epididymal cyst be removed?
If it is symptomatic
221
Describe how you would check for transillumination in an epididymal cyst.
It will transilluminate from behind the scrotum.
222
In which age group does epididymitis usually occur?
Young males
223
Give the two main organisms which commonly causes epididymitis.
- E.coli
| - Chlamydia
224
How do organisms usually spread to the epididymis?
- Retrograde spread from urethra
| - Blood stream
225
Give three risk factors for epididymitis.
- UTI
- Urethral instrumentation
- STI
226
Describe the presentation of epididymitis.
- Sudden-onset, tender swelling
- Dysuria
- Sweats/fever
227
How is epididymitis usually treated?
Antibiotics
228
What is hydrocele?
Excess fluid in the tunica vaginalis.
229
Describe a primary hydrocele.
- Occurs in the absence of disease in the testes
| - Tend to be large and tense
230
Who does primary hydrocele usually affect?
Young boys
231
Describe secondary hydrocele.
Represent reaction to testicular pathology (tumour/infection/torsion).
232
Describe the treatment for hydrocele.
- Aspiration or surgery
| - Can resolve spontaneously
233
What is varicocele?
Dilated veins of the pampiniform plexus
234
Which side is more commonly affected by varicocele?
Left side
235
Describe the classical appearance of varicocele.
Distended scrotal blood vessels that ‘feel like a bag of worms’.
236
Describe a possible symptom of varicocele.
May have a dull ache
237
What is the treatment for varicocele?
Surgery or embolisation
238
What is haematocele?
Blood in the tunica vaginalis.
239
What causes haematocele?
Trauma
240
How can haematocele be treated?
Drainage/excision
241
What is the most common tumour in males between 20 and 40yrs?
Testicular cancer
242
Describe the current trend in the incidence of testicular cancer.
Incidence is rising
243
Give four risk factors for testicular cancer.
- Cryptorchidism (undescended testes)
- Family history
- Previous testicular tumour
- Subfertility
244
What percentage of testicular cancers are malignant?
92%
245
What percentage of testicular cancers develop from germ cells?
>90%
246
Describe the growth rate and appearance of seminomas.
- Slow growing
| - Classic appearance
247
Give four types of testicular non-seminomas.
- Embryological carcinoma
- Yolk sac carcinoma
- Choriocarcinoma
- Teratoma
248
Describe the growth rate of testicular non-seminomas.
Rapid growth and metastases
249
What type of treatment do testicular non-seminomas respond well to?
Chemotherapy
250
What is the most common presentation of testicular cancer?
Painless lump in testes (80%)
251
Describe the length of the history in testicular cancer.
Short
252
Give three less common possible presentations that may indicate a testicular tumour.
- Hydrocele (may have bloodstained fluid)
- Unexplained pain in one testis
- Metastases
253
Which lymph nodes does testicular cancer spread to first?
Para-aortic
254
Give three investigations that should be carried out in suspected testicular cancer.
- USS same day
- Tumour markers
- CXR if respiratory symptoms
255
Give three tumour markers used in testicular cancer.
- alphafetoprotein
- b-HCG
- Lactate dehydrogenase
256
Why are tumour markers good at monitoring the disease in testicular cancer?
They have short half lives.
257
How would a malignant testicular cancer be treated?
Orchidectomy (testes and spermatic cord excised).
258
How would a testicular seminoma be treated?
Radiotherapy
259
How would a testicular teratoma be treated?
Cytotoxic chemotherapy
260
What supported treatment may be helpful in testicular cancer?
Semen collection, as treatment induces sterility.
261
The glomerular filtrate includes all of the components of the blood except....
(2 answers)
- Cells
| - Large or negatively charged proteins
262
What is the normal glomerular filtration rate?
120ml/min
263
What percentage of the cardiac output do the kidneys receive?
20%
264
How is eGFR predicted?
Looking at creatinine excretion.
265
Why is creatinine a good marker for GFR?
- In theory it is solely filtered by the kidneys
| - It is usually produced at a constant rate in the body
266
Give two groups of people in whom using creatinine to estimate GFR may be misleading.
- Body builders
- Elderly people
(Extremes of muscle mass)
267
In practise is creatinine solely filtered by the kidneys?
No, a small amount is also excreted.
268
Give three inhibitors of renal creatinine excretion.
- Trimethoprim
- Cimetidine
- Ritonavir
269
What happens to eGFR if creatinine excretion is inhibited?
Serum creatinine rises so it makes eGFR fall, causing suspected renal failure.
270
What condition results from the proximal tubule not receiving enough oxygen?
Acute tubular necrosis
271
What causes Fanconi syndrome?
Proximal tubular insult
272
Give four features of Fanconi syndrome.
- Glycosuria
- Acidosis (failure of urine acidification/bicarbonate reabsorption)
- Phosphate wasting (rickets/osteomalacia)
- Aminoaciduria
273
Give three stimuli for renin release.
- Decreased afferent arteriole pressure
- Decreased solute delivery to macula densa
- Sympathetic nervous system
274
Describe the effects of angiotensin II on the afferent and efferent arteriole.
It preferentially constricts the efferent arteriole.
275
Give two substances which drive cellular potassium uptake, and can be used to buffer acute changes.
- Insulin
| - Catecholamines
276
Give two other substances which determine renal excretion of potassium.
- Sodium
| - Aldosterone
277
Describe the relationship between creatinine and GFR.
Non-linear (large fall in GFR required to get small rise in creatinine).
278
Give four things that are taken into account when calculating eGFR.
- Age
- Gender
- Race
- Creatinine
279
Define chronic kidney disease.
Progressive and irreversible decline in renal function, resulting in decreased renal function >3months.
280
Give seven causes of chronic kidney disease.
- Diabetes
- Chronic glomerulonephrosis
- Hypertension
- Obstructive uropathy
- Cystic disease
- Acute kidney injury
- Age
281
Give four investigations carried out in chronic kidney disease.
- Creatinine
- Dipstick for proteinuria
- USS
- Blood biochemistry
282
What is the downside of using a urine dipstick to measure proteinuria, and how is this resolved?
Measures protein concentration, so can be affected by dehydration.
Use albumin-creatinine ratio.
283
How do the kidneys often appear on ultrasound in chronic kidney disease?
- Often small
| - Can be large if infiltrative disease
284
Give five findings on biochemistry in chronic kidney disease.
- Raised urea and creatinine
- Low calcium
- Increased phosphate
- Secondary hyperparathyroidism
- Reduced Hb
285
Describe stage 1 of CKD.
- eGFR>90ml/min
| - Evidence of renal damage
286
Describe stage 2 CKD.
- eGFR60-89ml/min
| - Evidence of renal damage
287
Describe stage 3 CKD.
EGFR30-59ml/min
288
Describe stage 4 CKD.
EGFR15-29ml/min
289
Describe stage 5 CKD.
EGFR<15ml/min
| End stage renal failure
290
What treatment is good at reducing urinary protein in diabetes?
ACEi
291
What is the usual general treatment for CKD?
Renal replacement therapy
292
Describe the regime for haemodialysis.
3 times a week for 4 hours.
293
Describe how peritoneal dialysis works.
- Drain sugary water into abdomen
- Waste moves into water by diffusion
- Water follows waste
- Sugar moves into blood
- Water follows sugar by osmosis
294
What may be a physiological issue with renal transplant?
May get reflux of urine into the new kidney.
295
Give two possible complications of CKD.
- Cardiovascular disease
| - Anaemia
296
How is cardiovascular disease in CKD treated?
Statins
297
Why does anaemia develop in CKD?
Iron deficiency caused by inability to excrete hepcidin, which is produced by the liver and inhibits iron absorption from duodenum.
Then decreased EPO.
298
How is anaemia treated in CKD?
IV iron
299
Give seven ways to assess fluid status.
- Urine volume
- Blood pressure
- Skin turgor
- JVP
- Oedema
- Listen to base of lungs for fluid
- Capillary refill time
300
What is the normal urine volume?
0.5ml/Kg/hr
301
Give five drugs that should be stopped if someone os dehydrated.
- ACEi
- ARBs
- Diuretics
- Metformin
- NSAIDs
302
What should be done to treat a dehydrated CKD patient?
- Stop potential precipitating drugs
| - Give IV fluids (with caution)
303
Are diuretics bad for the kidney?
They don’t work on the glomerulus so don’t really affect waste.
Therefore they aren’t that bad.
304
What is the likely diagnosis of a testicular lump if you can’t get above it?
(2 answers)
- Hernia
| - Hydrocele extending proximally
305
What is the likely diagnosis of a testicular lump if it is separate from the testis and cystic?
- Epididymal cyst
306
What is the likely diagnosis of a testicular lump if it is separate from the testis and solid?
(2 answers)
- Epididymitis
| - Varicocele
307
What is the likely diagnosis of a testicular lump if it is testicular and cystic?
Hydrocele
308
What is the likely diagnosis of a testicular lump if it is testicular and solid?
(Five answers)
- Tumour
- Haematocele
- Granuloma
- Orchitis
- Gumma
309
Define glomerulonephritis.
Inflammation of the glomerulus
310
What is glomerulonephrosis?
Injury to the glomerulus
311
What does irritation to the glomerular capillary endothelium result in?
Inflammation (nephritic syndrome)
312
What does irritation to the glomerular podocytes result in?
Foot process effacement (nephrotic syndrome)
313
What does irritation of the glomerular mesangium result it?
Mesangial proliferation
314
Describe what causes crescent formation in glomerulonephritis.
Proliferation of epithelial cells and macrophages with rupture of the Bowman’s capsule.
315
Give six possible clinical presentations of glomerulonephritis.
- Asymptomatic
- Rapidly progressing glomerulonephropathy
- Nephritic syndrome
- Nephrotic syndrome
- Macroscopic haematuria
- Chronic glomerulonephritis
316
What investigation should be carried out in suspected glomerulonephritis?
Urine dipstick
317
What causes nephritic syndrome?
Inflammation in the kidneys
318
Give three features of nephritic syndrome.
- Haematuria
- Moderate to severe hypertension
- Moderate to severe decrease in GFR
319
Give two primary causes of nephritic syndrome.
- IgA nephropathy
| - Mesangiocapillary glomerulonephropathy
320
Give five secondary causes of nephritic syndrome.
- Post streptococcal
- Vasculitis
- SLE
- Anti-glomerular basement membrane disease
- Cryoglobulinaemia
321
What type of vasculitis is usually renal vasculitis?
ANCA-associated small vessel vasculitis
322
How does renal vasculitis usually present?
Systemic inflammatory features and features of other organ involvement.
323
How is a diagnosis of renal vasculitis made?
ANCA
324
What might be seen on a renal biopsy in renal vasculitis?
Segmental glomerular necrosis with crescent formation.
325
What is used to induce remission in renal vasculitis?
- Steroids
- Cyclophosphamide
- Plasma exchange (trial)
326
What is being trialled to maintain remission in renal vasculitis?
Azathioprine
327
What is the most common glomerulonephropathy worldwide?
IgA nephropathy
328
What is IgA nephropathy?
Mesangial proliferative glomerulonephritis with diffuse mesangial IgA deposits.
329
Describe the pathology of IgA nephropathy.
Abnormal IgA produced which becomes deposited in the kidneys.
330
Describe the presentation of IgA nephropathy.
- Visible haematuria
- Proteinuria
- Mucosal infection
- Nephritic syndrome (5%)
331
Give two possible biopsy findings in IgA nephropathy.
- Diffuse mesangial IgA deposits
| - Subendothelial and subepithelial deposits (on EM)
332
What supportive treatment can be given in IgA nephropathy?
- BP control
- Diet
- Lower cholesterol
333
What is used to induce remission in IgA nephropathy?
- Steroids
| - Cyclophosphamide
334
What is used to maintain remission in IgA nephropathy?
Azathioprine
335
What is Henoch-Schonlein purpura?
A systemic variant of IgA nephropathy which causes a small vessel vasculitis.
336
Give four features of Henoch-Schonlein purpura.
- Purpuric rash on extensor surfaces
- Flitting polyarthritis
- Abdominal pain
- Nephritis
337
How is Henoch-Schonlein purpura diagnosed?
- Usually clinical
| - Confirmed with positive immunofluorescence for IgA and C3 in renal/skin biopsy
338
What is another name for anti-glomerular basement membrane disease?
Goodpasture’s disease
339
Describe the pathology in anti-glomerular basement membrane disease.
- Autoantibodies to type IV collagen in glomerular basement membrane
340
Give another feature of anti-glomerular basement membrane disease which does not occur in the kidneys.
Pulmonary haemorrhage may occur as type IV collagen is also found in the lungs.
341
Describe the presentation of anti-glomerular basement membrane disease.
- Haematuria
| - Nephritic syndrome
342
How is anti-glomerular basement membrane disease treated?
- Plasma exchange
| - Steroids +/- cytotoxins
343
What is the prognosis for anti-glomerular basement membrane disease?
Full recovery possible if treatment started early.
344
When does post-streptococcal glomerulonephropathy occur?
1-12 weeks after sore throat or skin infection.
345
What causes post-streptococcal glomerulonephropathy?
Streptococcal antigen deposited on glomerulus.
346
Describe the presentation of post-streptococcal glomerulonephropathy.
Nephritic syndrome
347
Describe the treatment available for post-streptococcal glomerulonephropathy.
Supportive
348
What is the prognosis in post-streptococcal glomerulonephropathy?
95% recover renal function
349
What is the most aggressive glomerulonephropathy?
Rapidly progressive glomerulonephropathy
350
Describe the biopsy findings in rapidly progressing GN.
Crescents affects most glomeruli
351
What are the three classifications of rapidly progressing GN.
- Immune complex disease
- Pauci-immune disease
- Anti-GBM disease
352
Give three causes of immune complex rapidly progressive GN,
- Post-infectious
- SLE
- IgA
353
Give three causes of Pauci-immune rapidly progressing GN.
- GPA
- Microscopic polyangiitis
- Churg-Strauss syndrome
354
Describe the presentation of rapidly progressing GN.
AKI +/- systemic features
355
What is the most common cause of death in ANCA+ve rapidly progressing GN?
Pulmonary haemorrhage
356
What is the treatment for rapidly progressing GN?
Aggressive immunosuppression (high does IV steroids, cyclophosphamide, +/- plasma exchange)
357
What is the 5 year survival in rapidly progressing GN?
80%
358
What are the three components of the nephrotic syndrome triad?
- Proteinuria
- Hypoalbuminaemia
- Oedema
359
Why does hypercoagulability occur in nephrotic syndrome?
Excretion of anticoagulation factors
360
Describe the blood pressure in nephrotic syndrome.
May be normal or slightly high.
361
Describe the GFR in nephrotic syndrome.
May be normal or mildly decreased.
362
Why does severe hyperlipidaemia occur in nephrotic syndrome?
Increased production of lipoproteins in response to low serum albumin.
363
Give four primary caused of nephrotic syndrome.
- Membranous GN
- Minimal change disease
- Focal segmental glomerulosclerosis
- Mesangiocapillary GN
364
Give four secondary causes of nephrotic syndrome.
- Diabetes
- SLE
- Amyloid
- Hepatitis B/C
365
What is the general pathology present in nephrotic syndrome?
Effacement of podocyte foot processes.
366
Give three complications of nephrotic syndrome.
- Susceptibility to infection
- Thromboembolism
- Hyperlipidaemia
367
Why does nephrotic syndrome cause increased susceptibility to infection?
Low serum IgG, low complement activity, and decreased T cell function due to loss of Ig in urine and immunosuppressive therapy.
368
Give the four main treatment strategies in nephrotic syndrome.
- Reduce oedema (diuretics)
- Reduce proteinuria (ACEi or ARB)
- Reduce risk of complications (anticoagulate, statins, infections)
- Treat underlying cause
369
What is membranous glomerulonephropathy?
Thickening of the glomerular capillary wall.
370
Briefly describe the pathology of membranous GN.
IgG and complement deposits in sub epithelial surface causing leaky glomerulus.
371
What causes primary membranous GN?
Glomerular podocyte membrane PLA2R antigen targeted.
372
Give four things which are associated with secondary membranous GN.
- Autoimmune conditions
- Viruses
- Drugs
- Tumours
373
Give two clinical features of membranous GN.
- Nephrotic syndrome
| - Benign urinary sediment
374
Give two ways to diagnose membranous GN.
- Serum PLA2R antibody
| - Renal biopsy
375
What percentage of people with membranous GN go into spontaneous remission?
30%
376
What supportive treatment is given in membranous GN?
Control of oedema, hypertension, hyperlipidaemia, and proteinuria.
377
Give two possible immunosuppressive treatments for membranous GN.
- Steroids
| - Cyclophosphamide
378
In which age group is minimal change disease much more common?
Children
379
Describe the pathology in minimal change disease.
Normal podocyte function lost, making glomerular filtration barrier abnormally permeable to proteins.
380
Give two clinical presentations of minimal change disease.
- Nephrotic syndrome
| - Benign urine sediment
381
What would the biopsy show in minimal change disease?
- Glomeruli appear normal by light microscopy
| - Electron microscopy shows effacement of podocyte foot processes
382
Describe the prognosis in minimal change disease.
Relapsing-remitting course, but does not progress to renal failure.
383
What is the first line treatment for minimal change disease?
Steroids
384
What are two possible second line treatments for minimal change disease?
- Cyclophosphamide
| - Cyclosporin
385
Give two general types of mesangiocapillary glomerulonephropathy.
- Immune complex mediated
| - Complement mediated
386
Describe immune complex mediated mesangiocapillary GN.
Driven by circulating immune complexes which deposit in the kidney and activate complement via classical pathway.
387
Give three potential underlying causes for immune complex mediated mesangiocapillary GN.
- Hepatitis C
- SLE
- Monoclonal gammopathy
388
Describe complement mediated mesangiocapillary GN.
Persistent activation of the alternative complement pathway.
| Extra-renal manifestations.
389
Give three biopsy findings in mesangiocapillary GN.
- Mesangial and endocapillary proliferation
- Thickened capillary basement membrane
- Double contouring (tramline) of capillary walls
390
Describe the prognosis in mesangiocapillary GN if no underlying cause is found.
Poor
391
Give two methods of treatment in mesangiocapillary GN.
- Treat underlying cause
| - ACEi/ARB
392
What causes primary focal segmental glomerulosclerosis?
Idiopathic
393
Give six causes of secondary focal segmental glomerulosclerosis.
- Vesicoureteric reflux
- IgA nephropathy
- Alport’s syndrome
- Vasculitis
- Sickle-cell disease
- Heroin use
394
Describe the presentation of focal segmental glomerulosclerosis.
- Nephrotic syndrome
- Proteinuria
- 50% have impaired renal function
395
Describe the biopsy appearance of focal segmental glomerulosclerosis.
Some glomeruli have scarring of certain segments.
396
What percentage of focal segmental glomerulosclerosis cases respond to steroids?
30%
397
Give two alternative treatment options for focal segmental glomerulosclerosis which is steroid-resistant.
- Cyclophosphamide
| - Ciclosporin
398
What percentage of patients with focal segmental glomerulosclerosis go into spontaneous remission?
<10%
399
What happens if focal segmental glomerulosclerosis goes untreated?
Most progress to end stage renal failure.
400
Give the three components in the physiology of an erection.
- Arterial dilatation
- Smooth muscle relaxation
- Corporeal veno-occlusive mechanism
401
Describe the blood supply to the dorsum of the penis.
- Internal iliac artery
- Common penile artery
- Dorsal penile artery
- Circumflex arteries
402
Describe the blood supply to the corpora cavernosa of the penis.
- Internal iliac artery
- Common penile artery
- Cavernosal artery
- Coiled helicine arteries
- Sinusoidal spaces
403
Describe the roots and role of the parasympathetic nerve supply to the penis.
- S2-4
| - Causes erections
404
Describe the roots and role of the sympathetic nerve supply to the penis.
- T10-L2
| - Causes ejaculation
405
Describe the anatomical course of the autonomic nerve supply to the penis.
Both sympathetic and parasympathetic carried in cavernous nerve, which passes posterolateral to the prostate.
406
Why is the position of the cavernous nerve in relation to the prostate important?
The cavernous nerve can be damaged during prostatectomy, causing erectile dysfunction.
407
Describe the nerve and blood supply to the penis in the flaccid state.
- Sympathetic tone
| - Arterioles constricted
408
Describe the nerve supply to the penis in the erect state.
Parasympathetic tone
409
Describe the blood supply to the penis in the erect state.
Arterioles dilated
410
Describe the smooth muscle tone in the erect penis.
Trabecular smooth muscle relaxation
411
Describe the neurotransmitter which initiates erection under parasympathetic stimulation.
Nitric oxide, which is released from parasympathetic nerves and endothelium.
412
Describe the intracellular signalling pathway initiated by nitric oxide which leads to erection.
- NO stimulates guanylate cyclase to convert GTP to cGMP
- This stimulates protein kinase G to close calcium channels and open potassium channels
- Fall in cytoplasmic calcium
- Smooth muscle relaxation
413
What substance breaks down cGMP to stop an erection?
Phosphodiesterase
414
Define erectile dysfunction.
The persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance.
415
What proportion of men have erectile dysfunction at age 40?
1 in 50
416
What proportion have erectile dysfunction at age 65?
1 in 4
417
Give five risk factors for erectile dysfunction that are common with CVS disease.
- Lack of exercise
- Obesity
- Smoking
- Hypercholesterolaemia
- Metabolic syndromes (diabetes)
418
Give six specific conditions which are risk factors for erectile dysfunction.
- Diabetes mellitus
- Cardiovascular disease
- Liver disease/alcohol
- Renal failure
- Trauma (pelvic fracture)
- Iatrogenic (prostatectomy)
419
Give five categories of organic causes of erectile dysfunction.
- Vasculogenic
- Neurogenic
- Hormonal
- Anatomical
- Drug induced
420
Which is the most common organic cause of erectile dysfunction?
Vasculogenic
421
What can a vasculogenic cause of erectile dysfunction be a warning for?
Heart disease
422
Give four indicators of erectile dysfunction being caused by a psychological aetiology.
- Sudden onset
- Good nocturnal and early morning erections
- Situational
- Younger patient
423
What is the cause of erectile dysfunction found to be in most patients?
No treatable cause is found in most patients (just start treating them)
424
Describe how hormonal factors can cause erectile dysfunction.
Low testosterone.
425
Give a congenital syndrome that can cause erectile dysfunction.
Kleinfelter’s Syndrome
426
What four physical examinations should be carried out in erectile dysfunction?
- BP and heart rate
- Genitalia
- Prostatic enlargement/cancer
- Hypogonadism
427
Give two physical signs of hypogonadism.
- Small testes
| - Secondary sexual characteristics
428
What is Peyronie’s disease?
Calcifications of the penile shaft so the penis bends.
429
What three laboratory tests should be carried out in erectile dysfunction.
- Fasting glucose
- Lipid profile
- Morning testosterone
430
Give four specialised tests which are carried out in unique cases of erectile dysfunction.
- Nocturnal penile tumescence and rigidity
- Intracavernosal injection test
- Duplex USS of penile arteries
- Arteriography
431
Give two methods of testosterone administration in erectile dysfunction due to testosterone deficiency.
- IM depot
| - Cream
432
Give a contraindication to testosterone replacement therapy in erectile dysfunction.
History of prostate cancer
433
What three things should be monitored when a patient is on testosterone replacement therapy for erectile dysfunction?
- Haematocrit
- Hepatic function
- Prostatic disease
434
What is the first line treatment for erectile dysfunction?
Phosphodiesterase (PDE5) inhibitor
435
Give three examples of phosphodiesterase inhibitors used to treat erectile dysfunction.
- Sildenafil (viagra)
- Tadalafil
- Vardenafil
436
Describe how phosphodiesterase inhibitors work to treat erectile dysfunction.
They help to maintain erection but it has to be initiated in other ways.
437
When is the efficacy of phosphodiesterase inhibitors reduced?
After a fatty meal
438
What should be checked before starting someone on a phosphodiesterase inhibitor?
Nitrates
439
Give eight side effects of phosphodiesterase inhibitors.
- Headache
- Flushing
- Dyspepsia
- Nasal congestion
- Dizziness
- Visual disturbances
- Back pain
- Myalgia
440
Describe a dosing regime for phosphodiesterase inhibitors which may be more effective than just using it when needed.
Daily dosing
441
When is viagra available on the NHS?
When there is an underlying disease.
442
Give three 2nd line treatments for erectile dysfunction.
- Vacuum constriction devices
- Intracavernosal injections
- Intraurethral alprostadil
443
Why don’t many people use vaccum constriction devices?
Causes pain
444
Describe intracavernosal injections.
Alprostadil injected into the corpora cavernosa.
445
Give three complications of intracavernosal injections.
- Penile pain
- Priapism
- Fibrosis
446
Give three side effects of intraurethral alprostadil.
- Pain
- Dizziness
- Urethral bleeding
447
What is the third line treatment for erectile dysfunction?
Penile prosthesis
448
Give two types of penile prosthesis.
- Malleable
| - Inflatable
449
Give two possible risks of an inflatable penile prosthesis.
- Infection
| - Failure
450
Define priapism.
Prolonged erection (>4hrs)/
451
What is the risk of priapism?
Permanent ischaemic damage to corpora.
452
How is priapism treated?
- Aspirate corpora with large needle
- If fails inject phenylephrenine
- Do surgery if all else fails
453
Give a type of drug which shouldn’t be given to patients with CKD.
NSAIDs
454
Describe the inheritance pattern in polycystic kidney disease.
Autosomal dominant, however there is also an autosomal recessive variant.
455
When does autosomal recessive polycystic kidney disease usually present?
In childhood
456
Describe the mutations associated with ADPKD.
Mutations in PKD1 or PKD2
457
Which mutation is more common in ADPKD?
PKD1
458
How does the prognosis differ with the different mutations in ADPKD?
PKD2 shows a slower course to end stage renal failure.
459
At what age do patients with ADPKD usually progress to end stage renal failure?
40-60yrs
460
When do symptoms and signs of ADPKD usually present?
At end stage renal failure.
461
Give some renal signs of ADPKD.
- Renal enlargement with cysts
- Abdominal pain
- Haematuria
- Cyst infections
- Renal calculi
- Hypertension
- Progressive renal failure
462
Why might abdominal pain and haematuria occur in ADPKD?
Secondary to haemorrhage within cysts.
463
Give five extrarenal manifestations of ADPKD.
- Liver cysts
- Intracranial aneurysm (subarachnoid haemorrhage)
- Mitral valve prolapse
- Ovarian cysts
- Diverticular disease
464
Give five general treatment methods for ADPKD.
- Monitor U&E
- Treat hypertension (ACEi)
- Treat infections
- Dialysis or transplant (ESRF)
- Genetic counselling
465
Give two methods of reducing pain in ADPKD.
- Laparoscopic cyst removal
| - Nephrectomy
466
Give three lifestyle changes which may help to treat ADPKD.
- Increase water intake
- Decrease salt intake
- Avoid caffeine
467
How are people screened for ADPKD?
Ultrasound
468
What are the criteria for a positive screening test for ADPKD for people aged 18-39yrs?
>3 unilateral or bilateral cysts
469
What are the criteria for a positive screening test for ADPKD for people aged 40-59yrs?
>2 cysts in each kidney
470
What are the criteria for a positive screening test for ADPKD for people aged >60yrs?
>4 cysts in each kidney
471
What organism causes chlamydia?
Chlamydia trachomatis
472
What organism causes gonorrhoea?
Neisseria gonorrhoeae
473
Compare the age distributions in chlamydia and gonorrhoea.
Gonorrhoea is usually more common in slightly higher age groups.
474
Is chlamydia more common in males or females?
Females
475
Is gonorrhoea more common in males or females?
Males
476
Compare the incidences of chlamydia and gonorrhoea.
Chlamydia is more common
477
Give five areas which can become infected with chlamydia/gonorrhoea in adults.
- Urethra
- Endocervical canal
- Rectum
- Pharynx
- Conjunctiva
478
Give two sites that are infected by chlamydia in the neonate.
- Conjunctiva
| - Pneumonia
479
Where does gonorrhoea infect in the neonate?
Conjunctiva
480
When/how are chlamydia/gonorrhoea transmitted from mother to neonate?
At the time of delivery
481
What are the symptoms of chlamydia/gonorrhoea in males?
Dysuria +/- urethral discharge
482
Compare the incubation periods for chlamydia and gonorrhoea in males.
Gonorrhoea has a shorter incubation period.
483
What percentage of males with chlamydia are asymptomatic?
At least 50%
484
What percentage of males which gonorrhoea are asymptomatic?
10%
485
Describe and compare the severity of symptoms of chlamydia/gonorrhoea in males.
Symptoms of gonorrhoea are more obvious/vigorous.
486
Compare the risk of complications in chlamydia and gonorrhoea in males.
Much more common to have symptoms in chlamydia.
487
Give two complications of chlamydia in males.
- Epididymo-orchitis
| - Reactive arthritis
488
What are the symptoms of chlamydia/gonorrhoea in females?
- Discharge
- Menstrual irregularity
- Dysuria
489
What percentage of females with chlamydia are asymptomatic?
Over 70%
490
What percentage of females with gonorrhoea are asymptomatic?
50%
491
Give three complications of chlamydia/gonorrhoea in females.
- Pelvic inflammatory disease
- Neonatal transmission
- Fitz Hugh Curtis Syndrome
492
How is chlamydia diagnosed?
Nucleic acid amplification test
493
How is gonorrhoea diagnosed?
- Gram stain microscopy
| - Culture/sensitivity testing
494
Where is the sample collected from in the female to test for chlamydia?
Self collected vaginal swab
495
Where is the sample collected from in the female to test for gonorrhoea?
Endocervix/rectum
496
Where is the sample collected from in males to test for chlamydia?
First void urine
497
Where is the sample collected from in the male to test for gonorrhoea?
Urethra/rectum
498
What is the first line treatment for chlamydia?
Doxycycline (7 days)
499
What is the second line treatment for chlamydia?
Erythromycin (14 days)
OR
Azithromycin in pregnancy
500
What is the treatment for gonorrhoea?
Ceftriaxone (IM)
| But continuous surveillance of antibiotic sensitivity
501
Give two steps, other than treatment, that should be carried out when someone presents with an STI.
- Partner notification
| - Test for other STIs
502
Give three features of pelvic inflammatory disease.
- Tubal factor infertility
- Ectopic pregnancy
- Chronic pelvic pain
503
What is it called when chlamydia/gonorrhoea infects the conjunctiva of a newborn?
Ophthalmia neonatorum
504
Describe Fitz High Curtis Syndrome.
Peri-hepatitis.
| Presents with RUQ pain but LFTs normal.
505
What is the diagnosis of a genital ulcer until proven otherwise?
Syphilis
506
Give two possible diagnoses from a genital ulcer.
- Syphilis
| - Herpes
507
What organism causes syphilis.
Treponema pallidum
508
Give three ‘types’ of syphilis that occur within 2 years of infection.
- Primary
- Secondary
- Early latent
509
Give four ‘types’ of syphilis that occur over 2 years after infection.
- Late latent
- CNS
- CVS
- Gummatous
510
Describe the infectivity of syphilis over 2 years after infection.
Doesn’t usually spread
511
Is syphilis more common in men or women?
Men
512
Describe the current trend in the incidence of syphilis.
Incidence is rising
513
Give two groups of people who are at risk of syphilis.
- MSM
| - Unprotected anal sex
514
How does primary syphilis usually present?
Primary chancre (painless ulcer)
515
Where does the primary chancre usually appear in primary syphilis?
95% of genital skin, but can also be on nipples/mouth
516
What is the incubation period for syphilis?
21-35days
517
Are ulcer usually solitary or multiple?
50/50
518
Give another sign which may occur along with the primary chancre in primary syphilis.
Regional lymph node enlargement 1-2 weeks after chancre.
519
What is the usual outcome of the primary chancre in syphilis?
Usually heals without scarring within 4-8 weeks.
520
When does secondary syphilis usually present?
6-8weeks after infection
521
What is the most common presentation of secondary syphilis?
Skin rash that can spread to palms and soles (70%)
522
Give 12 other manifestations of secondary syphilis.
- Mucous membrane lesions
- Lymphadenopathy
- Alopecia
- Hoarseness
- Bone pain
- Hepatitis
- Nephrotic syndrome
- Deafness
- Iritis
- Meningitis
- Cranial nerve palsies
- Constitutional
523
What percentage of the index patients’ partners will be infected with syphilis?
40-60%
524
What is the rate of vertical transmission in syphilis?
90%
525
How does syphilis pass from mother to child?
Across the placenta
526
What is the outcome of vertical syphilis transmission?
- 50% foetal loss/still birth
| - 50% congenital syphilis
527
Describe the four possible outcomes of syphilis if it is left untreated.
- No clinical consequences (65%)
- Late benign gummatous (15%)
- Neurosyphilis (10%)
- CV syphilis (10%)
528
Give two features of CNS syphilis.
- Dementia
| - Loss of proprioception
529
Give a feature of CV syphilis.
Thoracic aortic aneurysm
530
What is the mainstay of diagnosis in syphilis?
Serology
531
When might syphilis be diagnosed using microscopy?
From early moist lesions
532
What is the treatment for syphilis?
Penicillin injection
533
What is a UTI?
Combination of clinical features and the presence of bacteria in the urine.
534
Define bacteriuria.
Presence of bacteria in the urine.
535
Define pyuria.
Presence of leukocytes in the urine.
536
What is sterile pyuria?
Presence of leukocytes but no microorganisms in the urine.
537
In infancy, are UTIs more common in males or females?
Males
538
In childhood, are UTIs more common in males or females?
Females
539
What might a childhood UTI in a male suggest?
Structural abnormality
540
Give four UTIs of the lower urinary tract.
- Cystitis
- Prostatitis
- Epididymitis/orchitis
- Urethritis
541
Give an example of a UTI of the upper urinary tract.
Pyelonephritis
542
Give three classifications of UTIs.
- Asymptomatic bacteriuria
- Uncomplicated
- Complicated
543
Give two groups of patients in whom asymptomatic bacteriuria is very common.
- Catheterised patients (100%)
| - Elderly
544
Give an example of patients in whom a UTI is uncomplicated.
Non pregnant women
545
Give nine examples of when UTIs are complicated.
- Pregnant
- Men
- Catheterised
- Children
- Recurrent
- Immunocompromised
- Noscomial
- Structural abnormality
- Urosepsis
546
Give eight mechanisms that can cause UTIs.
- Inadequate ureteric reflex
- Short urethra in female
- Catheterisation allows colonisation
- Obstruction from BPH
- Bladder stones/tumour
- Low urinary volume
- Ureteric stones
- Stasis during pregnancy
547
Describe post-menopause UTIs.
- Loss of oestrogenisation
- High pH due to lack of lactobacilli producing lactate
- Reduction in mucus secretion
- Increased colonisation by colonic flora
548
Give four mechanisms that can cause UTIs in catheters.
- Insertion may carry organisms into bladder
- Hospitable environment in catheter
- Formation of biofilms
- Incomplete voiding
549
Are UTIs in short term catheters usually monomicrobial or polymicrobial?
Monomicrobial
550
Are UTIs in long term catheters usually monomicrobial or polymicrobial?
Polymicrobial
551
How are UTIs diagnosed in pregnancy?
- Culture rather than dipstick
| - Positive cultures should be confirmed with second sample if asymptomatic
552
Why should asymptomatic bacteriuria always be treated in pregnant women?
20-40% develop acute symptomatic pyelonephritis.
553
Give seven causative organisms of UTIs.
- E.coli
- Proteus
- Klebsiella
- Enterococci
- Staphylococcus saprophyticus
- Staphylococcus aureus
- Pseudomonas aeruginosa
554
What may a UTI caused by Staph.aureus suggest?
A deep seated infection
555
What other pathology, as well as UTIs, is Proteus associated with?
Renal stones
556
Describe why E.coli are good at causing UTIs.
They have fimbriae for bladder colonisation.
557
Why does proteus cause renal stones as well as UTIs?
Produces urease to increase pH, resulting in stone formation.
558
Describe the symptoms of a lower urinary tract infection.
- Frequency
| - Dysuria
559
Give the symptoms of an upper urinary tract infection.
- Systemic symptoms (fever)
| - Haematuria
560
How are UTIs diagnosed?
- Urine dipstick
- Microscopy
- Culture + sensitivity
561
What reading on a urine dipstick is highly predictive of a UTI?
Nitrates
562
Which two causative organisms of UTIs increase the pH of the urine?
- Klebsiella
| - Proteus
563
Why shouldn’t urine dipsticks be done from a catheter sample?
They will always contain bacteria
564
What three things can be looked for on urine microscopy in a suspected UTI?
- White cells
- Renal casts
- Bacteria
565
If epithelial cells are found in urine microscopy, what do they suggest?
Sample contamination
566
What are renal casts?
Precipitation of Tamm-Horsfall protein which are secreted in the urine in some diseases.
567
Give four causes of apparent culture negative pyuria.
- TB
- Mycoplasma
- Schistosomiasis
- Candida
568
Give five investigations that can be carried out in recurrent/complicated UTIs.
- Mid stream urine
- PV/DRE exam
- Post void bladder scan
- USS of renal tract/pelvis
- X-ray/flexible cystoscopy to rule out stones
569
Describe the management of asymptomatic bacteriuria in patients over 65yrs.
DO NOT TREAT
570
Describe the management of uncomplicated UTIs.
- Not necessary to send for microscopy
- 3 days antibiotics
- Adjunctive advice
571
Give three pieces of lifestyle advice that can help to prevent UTIs.
- Increase fluid intake
- Void pre and post intercourse
- Hygeine
572
Describe the management of complicated UTIs.
- Always send sample for culture
| - 7 days antibiotics
573
Which antibiotic is first line for UTIs?
Nitrofurantoin
574
Give two contraindications for nitrofurantoin.
- Reduced renal function
| - 3rd trimester of pregnancy
575
Which antibiotic used to be a first line treatment for UTIs but is not used commonly anymore due to resistance?
Trimethoprim
576
Give two examples of new antibiotics which can be used to treat UTIs.
What do they target?
- Fosfomycin
- Pivmecillinam
These target the cell wall.
577
What is prostatitis?
Inflammation/swelling of the prostate gland.
578
Give two ways that bacteria can cause prostatitis.
- Ascend from urinary tract
| - Haematogenous spread
579
Give three presentations of prostatitis.
- Acute bacterial
- Chronic bacterial
- Chronic pelvic pain syndrome
580
Describe the presentation of acute bacterial prostatitis.
- Systemically unwell
- Fever
- Rigors
- Significant voiding LUTS
- Pelvic pain
581
What will be found on DRE in acute bacterial prostatitis?
Boggy, exquisitely tender prostate
582
Describe the presentation of chronic bacterial prostatitis.
- Symptoms >3 months
- Recurrent UTIs
- Pelvic pain
- Voiding LUTS
- Uropathogens in urine +/- blood
583
Describe the presentation of chronic pelvic pain syndrome prostatitis.
- Chronic pelvic pain
- +/- LUTS
- +/- UTI
584
Give five investigations to carry out in prostatitis.
- Urinalysis and mid stream urine
- Bloods (including cultures)
- STI screen
- Urodynamic tests
- Imaging (TRUSS +/- CT)
585
Give four treatments for prostatitis.
- Start antibiotics immediately
- Treat pain
- Stool softener
- +/- alpha blocker
586
Describe the antibiotic treatment used for prostatitis.
Quinolones for 28 days
587
What is urethritis?
Inflammation of the urethra
588
Describe the presentation of urethritis.
- Pain
| - Difficult urination
589
What is the predominant cause of urethritis?
Sexually transmitted
590
Give four antibiotics that could possibly be used to treat urethritis.
- Ceftriaxone
- Azithromycin
- Oflaxacin
- Doxycycline
591
What is epididymo-orchitis?
Inflammation of the epididymis +/- testes
592
Give two different causes of epididymo-orchitis.
- Sexually transmitted pathogens ascending from urethra
| - Non sexually transmitted uropathogens spreading from urinary tract
593
Describe the symptoms of epididymo-orchitis.
- Acute onset
- Unilateral scrotal pain +/- swelling
- Urethritis symptoms
- UTI symptoms
594
Describe the signs of epididymo-orchitis.
- Unilateral swelling and tenderness of epididymis +/- testes
- Urethral discharge
- Hydrocele
- Erythema +/- oedema of scrotum
- Pyrexia
595
Give three investigations that can be carried out in epididymo-orchitis.
- Urethral smear
- Dipstick (mid stream urine)
- First pass urine for nucleic acid amplification test
596
Give five treatment options for epididymo-orchitis.
- Analgesia
- Antibiotics
- Sexual abstinence
- Supportive underwear
- Contact tracing
597
What is pyelonephritis?
Inflammation of the renal parenchyma and soft tissues of the renal pelvis/upper ureter.
598
What age and gender does pyelonephritis most commonly affect?
Women <35yrs
599
Give three signs of pyelonephritis.
- Significant sepsis
- Systemic upset
- Fluid depletion
600
Give three ways that infection can spread to cause pyelonephritis.
- Ascending
- Haematogenous
- Lymphatic
601
Give two causative organisms of pyelonephritis that usually spread haematogenously.
- S.aureus
| - Candida
602
Give the classic triad of symptoms in pyelonephritis.
- Loin pain
- Fever
- Pyuria
603
Give four investigations that can be carried out in pyelonephritis.
- Abdominal examination (including PV)
- Bloods including cultures
- USS (rule out obstruction)
- Mid stream urine
604
Give two typical findings on an abdominal examination in pyelonephritis.
- Tender loin
| - Renal angle tenderness
605
Give five treatment strategies for pyelonephritis.
- Fluid replacement
- Broad spectrum antibiotics (7-14days)
- Drain obstructed kidney
- Catheter
- Analgesia
606
Give two possible complications of pyelonephritis.
- Renal abscess
| - Emphysematous pyelonephritis
607
Describe emphysematous pyelonephritis.
Gas accumulation in the tissues.
| Rare but life threatening, may need nephrectomy.
608
What is the lifetime risk of developing urinary tract stones?
10-15%
609
Describe the current trend in the incidence of urinary tract stones.
Incidence is rising
610
Are urinary tract stones more common in males or females?
Males
611
What is the most common age for urinary tract stones to develop?
30-50yrs
612
What is the lifetime risk of recurrence of urinary tract stones?
>50%
613
Give three general causes of urinary tract stones.
- Anatomical
- Urinary factors
- Infection
614
Give four Congenital anatomical renal abnormalities that can increase risk of urinary tract stones.
- Horseshoe kidney
- Duplex kidney
- Pelviureteric junction obstruction
- Spina bifida
615
Give seven general pieces of advice that may help to prevent urinary tract stones.
- Overhydration
- Low salt (sodium) diet
- Normal dairy intake
- Healthy protein intake
- Reduce BMI
- Active lifestyle
- Citrus fruits
616
Why can citrus fruits help to prevent urinary tract stones?
Citrus inhibits stone formation
617
Give a specific preventative method to prevent uric acid stones in the urinary tract.
Deacidify urine (they only form in acidic urine)
618
Give four ways that cysteine stones in the urinary tract can be prevented.
- Excessive overhydration
- Urine alkalisation
- Cysteine binders
- Genetic counselling
619
Describe the theory behind why stones form in the urinary tract.
Nucleation theory suggests that stones form from crystals in supersaturated urine.
620
Give five things that may form urinary tract stones, in order of which is the most common.
- Calcium oxalate/phosphate (80%)
- Uric acid (10%)
- Struvite (5-10%)
- Cysteine (1%)
- Drugs (rare)
621
What causes struvite crystals to form in the urinary tract.
Infections with Proteus/Klebsiella cause splitting of urea and high pH.
622
What causes cysteine stones to form in the urinary tract?
Congenital
623
Describe the symptoms/signs of urinary tract stones.
- Asymptomatic
- Loin pain
- Renal colic
- UTI symptoms (dysuria, strangury, urgency, frequency)
- Recurrent UTIs
- Haematuria (visible or non-visible)
624
Describe the presentation of renal colic.
- Unilateral loin pain
- Rapid onset
- Unable to get comfortable
- Radiates to groin and ipsilateral testis/labia
- Associated with nausea/vomiting
- Worse with fluid loading
- Very severe
625
Give five investigations to do (or things to give) in a patient with renal colic.
- ABC and give analgesics/antiemetics
- Urinalysis
- Mid stream urine
- FBC, U and E, Calcium, Uric acid
- Imaging
626
Give three imaging modalities used to diagnose urinary tract stones.
Which is the gold standard?
- Non contrast CT of kidneys/bladder/ureters (GOLD STANDARD)
- Xray
- USS
627
Give five differential diagnoses of renal colic.
- Vascular (ruptured AAA)
- Bowel pathology (diverticulitis, appendicitis)
- Gynaecological (ectopic pregnancy, ovarian cyst/torsion)
- Testicular torsion
- Musculoskeletal
628
Give four steps in the management of renal colic.
- Analgesia (opiates/NSAIDs)
- Antiemetics
- May admit and give fluids (but fluids may make it worse)
- Observe for sepsis
629
Give five possible treatments for renal stones.
- Observation
- Extracorporeal shock wave lithotripsy
- Ureteroscopic laser
- Percutaneous nephrolithotomy
- Nephrectomy
630
When would extracorporeal shock wave lithotripsy be used to treat renal stones, and what is the issue with this?
- Used for stones up to 1-2cm
| - However fragments may cause problems
631
When would percutaneous nephrolithotomy be used to treat renal stones?
For larger stones
632
Give four treatment options for ureteric stones.
- Allow two weeks to pass
- Drainage if sepsis
- Extracorporeal shock wave lithotripsy
- Ureteroscopy
633
What size of ureteric stone will usually pass within two weeks?
<4mm
634
Give three treatment options for bladder stones.
- Observation
- Endoscopic lithopaxy
- Open/laparoscopic surgery
635
Give three complications of urinary tract stones.
- Pyonephrosis
- Obstruction
- Chronic renal damage
636
What is pyonephrosis?
Combination of infection and obstruction.
637
Describe the consequences of pyonephrosis.
- Can lose renal function in 24hrs
| - Systemic sepsis
638
Describe the management in pyonephrosis.
- IV antibiotics
- IV fluids
- Oxygen
- Drain kidney (nephrostomy/ureteric stent)
639
Give three ways that urinary tract stones can cause chronic renal damage.
- Abscess
- Fistulae
- Xanthogranuomatous pyelonephritis
640
What is the cut off for the concentration of pathogenic bacteria in the urine for a UTI to be diagnosed?
>10^5 /ml
