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Renal + GU Flashcards

1
Q

Name 3 processes that contribute to urine storage

A

Receptive relaxation

  • Detrusor stretching
  • no tension
  • no increase pressure

Symapthetic stimulation
T11 - L2
Detrusor relaxation

Pudendal nerve stimulation
S2 - S4
E.U.S contraction

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2
Q

factors affecting eGFR

A

Extreme muscle mass is misleading

  • bodybuilder
  • amputee
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3
Q

Kidney functions

A
  • Elimination of wate material
  • Regulation of volume + body fluid composition
  • Endocrine
    EPO, Renin, Active Vit D
  • Reabsorption
    Glucose, a.a, bicarbonates
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4
Q

how is urine transported in the ureter

A

Peristalsis

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5
Q

How is reflux of urine prevented at the bladder

A

Valvular mechanism
- At the Vesicoureteric
junction

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6
Q

What is the only protein in the urine

A

Tom Horsfall - Secreted by thick loop

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7
Q

Nerve that controls urine storage

A

Hypogastric plexus
T11 - L2
Noradrenaline NT

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8
Q

Nerve that controls voiding urine

A

Pelvic nerve
S2 - S4
Ach NT

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9
Q

Voluntary control of urine

A

Pudendal nerve
S2 - S4
Ach NT –> E.U.S

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10
Q

What controls the guarding reflux

A

Onuf’s nucelus

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11
Q

What is located in the PAG

A

Pontine mictruition centre

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12
Q

Function of the pontine mictruition centre

A
  • Inhibitory signals to the detrusor muscle
  • Excitatory signals to Onuf’s nucleus
  • Signals from T11-L2 (Hypogastric nerve) via sympathetic nerves
  • Bladder relaxes
  • Contraction of internal urethral sphincter
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13
Q

Voiding phase pathophsiology

A
  • Pontine mictruition centre sends excitatory signals to detrusor
  • Inhibits Onufs nucleus
  • Signals from S2-S4 (Pudendal nerve) via PNS
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14
Q

How much urine can the bladder store and when is the firsr sensation of bladder storage felt

A

500ml

100-200ml - first sensation

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15
Q

Name the 3 common sites for kidney stones to lodge

A
  • Pelviureteric junction
  • Pelvic brim
  • Vesicoureteric junction
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16
Q

What are most kidney stones made from

A
  • Calcium oxalate
  • Calcium phosphate
  • Mg ammonium phospahte
    (Struvite)
  • Uric acid
  • Cystine
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17
Q

Name 2 factors contributing to urine supersaturation

A
  • decreased urine volume
  • Increase/decrease urine
    pH
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18
Q

Name 2 factors decreasing the action of stone forming inhibitors

A

Mg

Citrate

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19
Q

Name 4 foods that increase oxalate diet intake

A

Spinach
Chocolate
Tea
Rhubarb

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20
Q

Name 1 complication of a stone causing obstruction within the urinary tract

A

Hydronephrosis

  • Proximal dilatation of ureter and renal pelvis due to obstruction
  • can cause lasting kidney damage
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21
Q

What causes hypercalciuria leading to calcium stones

A

Hyperparathyroidism
Excessive Ca2+ intake
Primary renal disease - PCKD

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22
Q 
Stone composition:
Struvite stones 
- metals 
- assosc
- what favours this stone 
  formation
A

Ammonium
Mg
Ca2+

Chrnoic UTIs

  • Klebsiella
  • Pseudomonas

Alkaline urine pH
Increase ammonium conc

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23
Q

Stone composition:
Uric acid
- Assosc
- which patients are high risk

A

Hyperuricaemia
Clinical gout
Dehydration

Pts with ileostomies

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24
Q

Renal colic presentation

- Sx

A 
Pain
- Acute flank (Stabbing)
- Radiation:
  Loin/Groin/Genitals 
Nausea
Vomitting 
Sweating

Triad:
Fever
Acute flank pain
Vomitting

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25
Bladder stones signs
- Urinary frequency | - Haematuria
26
Urethral stones signs
Bladder outflow obstruction - Anuria - Painful bladder distension
27
Renal colic signs
- Can't lie still - Nausea - Haematuria - Dysuria - Strangury severe pain strong desire to urinate
28
Renal colic differential diagnosis
Ectopic pregnancy Appendicitis Diverticulitis Testicular torsion
29
Renal colic investigations
Urine dipstick - Haematuria Midstream urine - Culture + sensitivity 1st line: - KUB X-ray GOLD/ Diagnostic: - non contrast KUB CT - No contrast so no renal damage
30
Indications for renal colic intervention
- Persistent pain - Infection - Failure of stone to pass
31
Renal colic management
NSAIDs - Diclofenac (75mg) Fluids Abx if infection - Gentamicin - Cefuroxine
32
What size must a stone be to require medical intervention
Stone < 5mm - spontaneous resolution Stone > 5mm or pain not resolving - medical expulsive therapy
33
What can be used to help aid spontaneous passage of stones
Tamsulosin - Alpha blocker - promotes expulsion
34
What is AKI
clinical syndrome of decreased renal function occuring over hours/days - Usually reversible
35
Critera for AKI diagnosis
Rise in creatnine: >26micrmol/L in 48hrs Rise in creatnine >1.5x baseline within 7 days Urine output < o.5ml/kg/h for 6hrs
36
name and describe the classification used in AKI
RIFLE ``` R - Risk I - Injury F - Failure L - Loss E - End stage kidney disease ```
37
Limitations of using creatnine as a biomarker
Muscle mass | Dilution
38
AKI risk factors
``` Pre-existing CKD Age Male Co-morbidities - DM - CVD - Cancer ```
39
How can AKI be classified
Pre renal Intra renal Post renal
40
Pre renal AKI causes
Hypovolemia - Trauma - Burns Decrease CO - MI Systemic vasodilation - Sepsis - Anaphalaxis Afferent A vasoconstriction - NSAIDs Efferent A vasodilation - ACEi/ARB
41
Inra renal causes of AKI
Glomerulonephritis - SLE - Infection Acute interstitial nephritis - Drugs - Infection Acute tubular necrosis - Secondary to ischaemia due to hypovolemia Vasculitis - SLE
42
Post renal AKI causes
Obstructive uropathy - Kidney stones - Strictures (Ureter/Urethral) - Renal tract malignancy - BPH - Prostatic cancer
43
How can you differentiate between pre or intra renal AKI causes from urine tests
Intra renal has HIGH Na+ urine compared to pre-renal
44
Causes of Acute tubular necrosis
- Gentamicin - NSAIDs - ACEi - Acute pancreatitis - MI / CCF - Diuretics - Haemorrhage
45
AKI presentation
- Anuria Uraemia sx: - Fatigue - Seizures - Weakness - nausea - confusion - vomitting Dehydration --> Poor tissue tirgor
46
AKI emergencies and consequent complications
Hyperkalaemia - Arrhythmias Fluid overload - Heart failure - Pulmonary oedema Metabolic acidosis Uraemia - Encephalopathy - Pericarditis No urine produced
47
AKI differential diagnosis
- AAA - DKA - CKD - Heart failure - Metabolic acidosis
48
AKI investigations
``` Urinalysis: Dipstick --> Infection Haematuria Proteinuria Glomerulonephritis ``` Imaging: - US --> obstruction - CT-KUB --> Retroperitonea; fibrosis
49
Pre renal AKI tx
- Fluids | - Abx if sepsis
50
Post renal AKI tx
Catheter | Nephrostomy
51
AKI general tx
Stop nephrotoxic drugs - NSAIDs - ACEi Fluid balance - monitor intake - monitor urine output
52
Indications for dialysis after AKI
- Pulmonary oedema - Severe metabolic acidosis pH < 7.1 - Removal of causative nephrotoxic drugs
53
What is CKD
Long standing reduction in kidney function - Permanent - Progressive
54
What GFR is assosciated with CKD
GFR < 60ml/min/1.73m2 With or without Albuminuria
55
CKD causes
- Diabetes - HTN - Glomerulonephritis - Age related decline - Congenital --> PCKD - Amyloidosis - SLE Tubulointerstitial disease 1 --> UTI / Stones 2 --> Drugs / toxins
56
what is the typical decline in GFR as we age
2ml/ min/ year
57
CKD presentation
``` Early: Malaise Loss of appetite Uraemic: Yellow Itchy Anaemia Fluid overload: Oedema - Pulmonary - Peripheral Kidneys apprear SMALL ``` Late: Myoclonus Oligouria
58
Where do renal cell carcinomas arise from
Proximal convuluted tubulal epithelium
59
RCC risk factors
- Smoking - Obesity - Von - hippel lindau syndrome - Petroleum - Asbestos - Leather tanners
60
Renal cell carcinoma presentation
- Haematuria - Loin/Flank pain - Mass - Fever - Weight loss - Malaise
61
Renal cell carcinoma complications
``` L. sided varicoceles - Renal tumour obstructs gonadal vein - Impedes drainage of testes - Dilatation of testicular veins ``` IVC invasion - Metastases - Lung - Bones - Liver
62
Renal cell carcinoma investigations
US - Distinguish cyst from complex cyst or tumour CT MRI - Tumour staging CXR - Cannonball mets Bloods - Polycythaemia - Raised ESR
63
What is lined by transitional cells
``` calyces renal pelvis ureter bladder urethra ```
64
Risk factors fot TTC
``` Smoking Beta - napthylamine Azo dyes Aoromatic amines Aldehydes - Hairdressers - Painters - Rubber industry Family hx ```
65
TCC presentation
``` Painless haematuria Sx suggestive of UTI: - Frequency - Urgency - Dysuria Pain Voiding irritability ```
66
TCC investigation
- Cystoscopy with biopsy | - CT
67
TCC tx
- Transurethral resection of the bladder - Chemo
68
Which cells do testicular tumours arise from and what are the 2 different forms
Germ cells - Seminomas - Teratomas
69
Testicular tumour presentation
- Painless lump in testicle - Haemospermia - Hydrocele
70
Testicular tumour investigations
- Biopsy + histology - US ``` Serum tumour markers AFP B-hCG -Raised AFP and B-hCG --> Teratoma - Raised B-hCG --> Seminoma - No AFP in pure seminoma ```
71
Testicular tumour tx + what should be offered
- Radical orchidectomy - Chemotherapy - Sperm banking should be offered
72
Prostate cancer | - What is the cancer that arises from the peripheral zone
Adenocarcinoma
73
what mutation results in prostate cancer
BRAC1 | BRAC2
74
Name sites of prostatic cancer metastatic spread
- Lymph nodes - Bone (sclerotic lesions) - Brain - Liver - Lung
75
Name the predisposition gene for prostatic cancer
HOXB13
76
Prostatic cancer presentation
- Nocturia - Hesitancy - Poor stream - Terminal dribling - Obstruction --> Urinary retention
77
Prostatic cancer investigations
1st = DRE - Hard irregular lump - nobbly - loss of central culcus 2nd = PSA 3rd = DIAGNOSTIC trans-rectal US + biopsy - multiple biopsies required as multifocal tumour
78
Grading trans-rectal US abd biopsy for prostatic cancer
Gleason grading
79
What is BPH
- Transitional zone enlargement - Hyperplasia of glandular and musculofibrous elements - Normal process in ageing males
80
Function of 5 - alpha reductase
Conversion of testosterone to dihydrote.. | - More potent
81
How does ageing lead to BPH
- Increase 5-alpha reductase activity - Increase dihydrotestosterone - cells is transitional zone grow in response to androgens - leads to LUTS sx
82
BPH presentation
``` sx - SHED + FUND S - stream changes H - Hesitancy E - Emptying incomplete D - Dribbling ``` F - Frequency U - Urgency N - Nocturia D - Dysuria - Overflow incontenence - Haematuria - Loin/Pelvic pain
83
BPH Investigations
DRE - Enlarged but smooth PSA Midstream urine sample - infection - Urine flow rates - Frequency volume chart Transrectal US + biopsy
84
What urinary flow rate indicates outflow obstruction
Max rate < 10ml/sec
85
Non pharmacological tx for BPH
- Avoid caffine - Void 2x in a row to aid emptying - Relax when voiding - Bladder training
86
BPH Pharmacological tx
1st = Tamsulosin - Alpha 1 antagonist - Relax SM in bladder neck and prostate increasing flow rate ``` 2nd = Finasteride - 5 alpha reductase inhibitor - Inhibits dihydrotestosterone conversion - excreted in semen so wear condom ``` Surgery
87
Surgery for BPH indications
Recurrent haematuria | Acute urinary retention
88
What is TURP | - name 4 complications
Transurethral resection of the prostate - Bleeding - Infection - Incontinence - erectile dysfunction - Urethral strictures
89
LUTS red flags
- Lower back pain - Back pain that disrupts sleep - Frank haematuria - Blood in ejaculate - Family hx - weigth loss
90
LUTS voiding sx
``` SHED S - Stream changes H - hesitancy E - Emptying incomplete D- Dribblling ```
91
LUTS storage sx
``` FUND F - Frequency U - Urgency N - Nocturia D - Dysuria ```
92
What type of incotenence is assosciated with LUTS
Overflow | - Leaking urine during day and night
93
Acute urinary retention causes
- Alcohol - Urethral strictures - BPH - Anti-cholinergics - Constipation - Infection
94
Acute urinary retention tx
Catheter Tamsulosin Finasteride
95
Describe chronic urinary retention
Insidious + painless | - Incomplete bladder emptying so increased infection risk
96
Chronic urinary retention causes
BPH Prostatic cancer Pelvic malignancy Rectal surgery
97
Chronic urinary retention presentation
Overflow incontinence - Leaking/wetting bed Loss of appetite Constipation Distended abdo Increased UTI risk
98
What is pyelonephritis
Infection of renal pelvis
99
What bacteria are assosciated with pyelonephritis
1. E.coli - Bowel flora | 2. S.aureus - Infective endo
100
Pyelonephritis presentation
Triad: - Loin pain - Fever - Pyuria ``` Rigors Tenderness Nausea + vomitting Frequency Elderly --> Confusion ```
101
Pyelonephritis investigation
Abdo exam: Tender loin Bloods: FBC,U+E,CRP ``` MSU Microscopy + culture - Cloudy - Leukocytes - Blood - Nitrate - Protein ``` USS - rule out obstruction
102
CKD investigations
Bloods - eGFR - Creatnine ratio - U+E - PTH - Glucose - Hb Urine - dipstick - MC&S - A:Cr Imaging - US --> Small
103
Rule of thumb + generalised cancer sx - bladder - RCC/stones - Testicular tumour
- Painless haematuria - Haematuria + loin pain - Testicle lump + pain
104
Pyelonephritis tx
``` Fluids Abx: Broad spectrum - Co-amoxiclav - Ciprofloxacillin +/- Genatmicin ```
105
Pyelonephritis complications
- Renal abscess - Emphysematous pyelonephritis
106
Name the anatomical predisposition to have chronic pyelonephritis
Vesicoureteric reflux
107
UTI causes
- E-coli - Klebsiella pneumoniae (hospital catheter) - Proteus mirabillis (renal stones)
108
UTI risk factors
``` Female Previous UTI Sexual activity Pregnancy Catheter Obstructed urinary tract ```
109
UTI location LUTI UUTI
LUTI - Cystitis - Prostatitis - Urethritis - Epididymo-orchitis UUTI - Pyelonephritis
110
Examples of complicated UTIs
Male Immunocompromised Pregnancy Children
111
Lower UTI presentation
``` Frequency Dysuria Haematuria Suprapubic pain Tenderness Smelly urine ```
112
Upper UTI presentation
``` Loin pain tenderness nausea vomitting fever ```
113
UTI investigations
MSU - MC&S - Dipstick: blood/nitrates/leucocytes Bloods - if systemically unwell - FBC - U+E - CRP - Blood cultures
114
UTI management
fluids Uncomplicated UTI 1st = Trimethoprim 2nd = Co-amoxiclav Ciprofloxacin Complicated UTI - Nitrofurantoin
115
What is cystitis - chief organism - Risk factors
urinary infection of the bladder E.coli - Urinary stasis - Bladder stones - Incomplete bladder emptying
116
What is prostatitis - investigations - tx
Infection and inflamm of prostate gland Investigations - DRE (hot + tender prostate) - Dipstick - MC&S Tx Acute: -IV gentamicin/co-amoxiclav - Trimethoprin
117
STI general rule of thumb - Urethral discharge - Genital ulcers - Vaginal discharge
- Chlamydia Gonorrhea - Syphillis Herpes - Chlamidya Gonorrhea
118
What is gonorrhoea | - presentation
Neisseria gonorrhoea - Intracellular gram -ve diplococcus - Green vaginal discharge - lower abdo pain - post-coital/inter-menstrual bleeding
119
Gonorrhoea tx - normal - pregnant
1g IM Ceftriaxone + Azithromycin Pregnancy: - Enthromycin
120
STI Investigations
Nucleic acid amplification test Female - vaginal swab Male - first pass urine MC&S - genital secretions Blood cultures Urine dipstick - excludes UTI
121
Gonorrhoea tx
- IM Ceftriaxone with oral Azithromycin - contract tracing - educate pts
122
syphillis tx
penicillin IM
123
what is the only glomerular disease that doesn't progress to kidney failure
Minimal change disease | - Children
124
What is glomerulonephritis and what is its link to: - nephrotic syndrome - nephritic syndrome
Glomerulonephritis is a spectrum of diseases and presentation could be: Proteinuria side - nephrotic Haematuria side - nephritic
125
Glomerular disease aetiology
Inflammation: SLE Anti-GBM Small vessel vasculitis Infection: Streptococcus Metabollic DM - nephropathy
126
What is the nephrotic syndrome presenting triad
- Proteinuria >3.5g/24hrs (Frothy urine) - Hypoalbuminaemia <30g/L - Oedema Periorbital Ascites Peripheral
127
How does hyperlipidaemia occur in a pt with nephrotic syndrome
Liver goes in to overdrive due to protein loss - Increase cholesterol production - Hyperlipidaemia
128
Nephrotic syndrome pathophysiology
Structural and functional podocyte abnormalities - loss of podocytes - loss in filtration barrier - proteinuria
129
Nephrotic syndrome aetiology - primary - Adults - Children
Idiopathic ``` Adults - Membranous nephropathy - Focal segmental glomerulosclerosis - Minimal change disease ``` Kids - Minimal change disease
130
Secondary causes of nephrotic syndrome
DDANI ``` D - Diabetes D - Drugs - NSAIDs A - Autoimmune - SLE N - Neoplasia - myeloma I - Infection - Hep B/C ```
131
Nephrotic syndrome presentation
- pitting oedema - frothy urine - tiredness - xanthelasma
132
Nephrotic syndrome differential diagnosis
CCF But no - No increase JVP - Pulmonary oedema
133
Nephrotic syndrome investigations
- Renal biopsy | - Urine dipstick
134
Nephrotic syndrome complications and tx
Thromboembolism - LMWH - Warfarin Infection - Vaccinations Hyperlipidaemia - Statins
135
Nephrotic syndrome tx
1. Reduce oedema - Furosemide - Salt + fluid restriction 2. Tx underlying cause 3. Reduce proteinuria - Ramipril - Decrease protein in diet
136
What is the charecteristic triad presentation of Nephritic syndrome
- Haematuria visible or non visible - Proteinuria < 2g in 24hrs - HTN Glomerulus damaged restricts blood flow leads to compensatory High BP
137
Nephrotic syndrome aetiology
- IgA nephropathy IgA deposition in mesangium - Post streptococcal GN Strep pyogenes - Good pastures disease Anti-GBM - SLE - Systemic sclerosis
138
Nephritic syndrome presentation
``` Haematuria Proteinuria HTN Oedema Oligouria Uraemia - Pruritus - Lethargy - Nausea ```
139
Nephritic syndrome investigations
Urinalysis - Dipstick - RBC casts in urine Bloods - FBC - U&E - LFT - CRP - Ig Renal biopsy - DIAGNOSTIC
140
Nephrotic syndrome tx
- Tx underlying cause - ACEi Reduce proteinuria - Cortiocsteroids
141
4 types of incontenence
urgency stress overflow neurological
142
Urgency incontenece - Pathophsiology - sx - investigation - tx
Detrusor instability - uninhbited detrusor muscle contraction leads frequent urination Sx - Nocturia Investigations - Bladder diary - Urodynamics ``` Tx - 1. Bladder retaining 2. Oxybutynin - Anticholinergics 3. Cut out caffine and alcohol ```
143
Stress incontinence - pathophysiology - aetiology - tx
Increase abdo pressure leads to urine leakage - cough - sneeze - laugh - standing up Sphincter weakness - post - prosatectomy - post - childbirth Keegle excercises
144
Overflow incontenence - Aetiology - Sx - Tx
Emptying issues - BPH - Urethral strictures - Ineffective detrusor Sx: - Hesitancy - Poor stream - Straining - Dribbling Tx: - Catheter - Alpha blocker (BPH)
145
Neurological causes of incontinence
Parkinsons Multiple sclerosis - Damage nerves of mictruiton reflex
146
How does DM lead to incontinence
- Autonomic neuropathy - Decreased detrusor excitability - Distended atonic bladder - Large residual volume - Infection risk
147
PCKD complications assosciated with disease
PKD = SAH + MVP - Subarachnoid haemorrhage - Mitral valve prolapse - Liver cysts
148
PCKD presentation
Asymptomatic until cysts increase size or haemorrhage - Loin pain - Haematuria (visible) - Cyst infection - HTN - Renal failure
149
Tamsulosin S/E
``` Drowsiness Dizziness Reduced BP Dry mouth Ejaculatory failure ```
150
Finasteride S/E
- Reduced libido | - Impotence
151
Non malignant scrotal disease - separate + cystic - seperate + solid - Testicular + cystic - Testicular + solid
- Epididymal cyst - Epididymitis Varicocele - Hydrocele - Tumour Orchitis Haematocele
152
Epididymal cyst - fluid apperance - location in relation to testis
- Clear and milky - Above and behind testis - Palpable quite separetly from cyst - Transilluminate

Phase 2a (11 decks)

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