Renal GU FCM Flashcards
what is the most common form of bladder cancer
transitional cell carcinoma
others include squamous cell and adenocarcinoma
How does bladder cancer present?
haematuria dysuria urinary frequency lower back, pelvic or lower abdominal pain weight loss/fatigue
How can bladder cancer be investigated?
Cytoscopy - look inside bladder (+take a biospy).
urinanalysis and CT scans can also be useful
What does management of bladder cancer involve?
dependent on stage of bladder cancer
low grade - surgical removal may be favoured if it hasn’t metastasised.
IV or systemic chemotherapy
other options include radiotherapy, immunotherapy or targeted therapy
what are most prostate cancers?
adenocarcinomas
How can prostate cancer/carcinoma present?
unexplained. ..
- lower back pain
- lethargy
- erectile dysfunction
- hematuria
Weight loss and also lower urinary tract symptoms - hesitancy, frequency, urgency, terminal dribbling and/or overactive bladder.
What examinations/investigations are done when prostate cancer is suspected?
DRE (physical rectal exam)
PSA testing
Transrectal US + biopsy
(additional MRI imaging)
How is prostate cancer managed?
dependent on the prognostic risk accounting for the clinical staging, PSA test and Gleason score.
TNM Stage
1 = watchful waiting/active surveillance
2 = radical treatment - radical prostectomy, external beam radiotherapy and brachytherapy
3 = adjunctive & palliative treatment - chemo & hormonal therapy
things to consider = pt age & preference, co-morbidities,
Where does renal cell carcinomas originate?
in the lining of the proximal convoluted tubule
commonest type of kidney cancer in adults
What does renal cell carcinoma present with?
hematuria persistent back or flank pain loss of appetite/unexplained weight loss tiredness & possibly fevers excessive hair growth in women lump in the abdomen and flank.
How is renal cell carcinoma investigated?
CT scan
abdominal or kidney US + biopsy
Urine examination
FBC, LDH, LFTs
How is renal cell carcinoma managed?
Dependent on the stage
Earlier stages may indicate surgical intervention - removing tumour via partial/full nephrectomy alongside some adjunctive therapy
cryoablation and radio-frequency ablation
Targeted therapy/immunotherapy or radiation therapy
What is key about Wilm’s tumour?
a kidney cancer which primarily affects children
How does Wilm’s tumour present?
constipation abdo pain/discomfort or abdo swelling nausea & vomiting weakness, fatigue and loss of appetite fever and SOB hematuria, HTN palpable abdominal mass
How is wilm’s tumour investigated?
Abdo X-ray/ US + biopsy
blood and urine tests
How is Wilm’s managed?
in non-metastatic cases the main treatments include
- surgery (nephrectomy)
- chemotherapy
- radiation therapy
What are the 2 types of testicular cancer?
Seminoma = older age/gradual onset Non-seminoma = younger age/ more agressive/acute onset
How will testicular cancer present?
testicular pain or discomfort /dull ache
testicular swelling
lower abdo/back pain
enlargement of breast tissue - gynaecomastia
lump/enlargement within either testes
heaviness in scrotum
sudden collection of fluid in scrotum
How is testicular cancer investigated?
male genitalia examination
US to examine internal structure of testes
Blood tests - B-chorionic gonadotropin and a-fetoprotein (usually elevated)
What does management of testicular cancer involve?
surgery to remove the testicles and sometimes the nearby lymph nodes
radiation therapy/chemotherapy used either prior ot in adjunct to surgery
How does benign prostatic hyperplasia (BPH) present?
urinary urgency or frequency nocturia difficulty initiating urination weak stream - intermittence terminal dribbling inability to completely empty bladder associated with UTIs or hematuria
how is BPH examined and investigated?
PR Exam - check prostate enlargement
Urine test - rule out infections
Blood tests - U&E to check renal function
PSA blood test - usually raised in BPH
How is BPH managed?
usually started on alpha-blockers which makes urinating easier 5-alpha reductase inhibitors prevent hormone changes or Tadalafil (PDE5 inhibitor)
minimally invasive/surgical therapy or laser therapies
- prostatic urethral lift
- embolisation
How does acute Glomerulonephritis present?
puffiness in face urinating less often hematuria/dark coloured urine fluid in lungs - presents as a cough high BP
How does chronic Glomerulonephritis present?
swelling in face and ankles frequent nocturia abdominal pain frequent epistaxis bubbly/foamy urine
How do we investigate glomerulonephritis?
- urine tests
- blood -creatinine and Blood urea nitrogen (BUN)
- imaging tests
- biopsy - determine cause & confirm diagnosis
How do we manage glomerulonephritis?
dependent on the extent of GN and the underlying cause
antibiotics in infective cases
Control HTN using ACEi or ARBs
chronic GN may involve dietary changes and taking diuretics to reduce oedema
corticosteroid given to suppress and autoimmune attacks
What can cause glomerulonephritis?
Infections
Immune diseases
Scarring due to HTN, DM or focal segmental glomerulosclerosis
Vasculitis
What are the 2 main characteristic of an AKI (/acute renal failure)?
Abnormal increase in creatinine
Drop in urine output
What are the causes of AKI divided into? what do each involve?
Pre-renal - reduced perfusion to the kidneys causing GFR to drop. examples include Hypovolemia, lower CO and antihypertensives
Renal - toxins & drugs, vascular conditions, abnormalities in glomerulus, tubular problems or interstitial problems
Post-renal - mainly due to obstruction. examples include stones, blocked catheter or enlarged prostate.
How does AKI present?
- decreased urine output
- fluid retention = swelling of legs, ankles and feet
- SOB, chest pain/pressure
- nausea or coma in severe cases
- creatinine rise of 26mmol/L within 48hrs
How do we investigate an AKI?
measure urine output - monitor over 24hrs
urine tests/ urinalysis
Blood tests - rapidly rising levels of urea & creatinine
imaging - US or CT to look for any structural abnormalities
Biopsy - guides/confirms diagnosis as well as aiding staging of AKI
How is AKI managed?
based upon cause - start by managing any of the underlying causes
offer supportive tx on maintaining hydration
consider stopping any nephrotoxic medication
close monitoring of creatinine
diuretics to reduce swelling,
what is classified as chronic renal failure/kidney disease?
reduction in renal function, structural damage or both presenting fro 3 months with associated health implications
what are some causes of CKD?
Type 1 &2 diabetes HTN Glomerulonephritis Polycystic kidney disease Prolonged obstruction vesicoureteral reflux recurrent UTI
How does CKD present?
nausea & vomiting loss of appetite fatigue & weakness persistent itching sleep problems/insomnia swelling in feet/ankles changes to urine output decreased mental 'sharpness' SOB, chest pain muscle twitching
How is CKD investigated?
Blood test - U&Es
urine tests
Imaging tests
Biospy
How is CKD managed?
identify and treat underlying cause
monitoring of renal function - creatinine, eGFR, ACR
dialysis
renal replacement therapy - definitive
What characterises nephritic syndrome?
what causes it?
nephritic syndrome is characterised by hematuria
also has mild proteinuria and very high BP (malignant HTN)
cause = endothelial wall damage mediated by immune-complex formation (IgA nephropathy)
post infection, lupus, infective endocarditis
what characterises nephrotic syndrome?
what causes it?
involves heavy proteinuria (>3.5g/day)
hypoalbuminaemia and fluid overload
causes = structural damage to slit diaphragm, foot processes and depleting in podocyte numbers
How does nephritic syndrome present?
Haemturia oedema reduced urine output uraemic symptoms - fatigue and tiredness HTN, Oliguria
how does Nephrotic syndrome present?
oedema frothy urine fatigue poor appetite recurrent infections SOB
How is nephritic syndrome investigated?
urine dipstick - leukocytes,protein and blood
urine ACR
acute renal screen
Acute renal screen = tests measure the amounts of various substances, including several minerals, electrolytes, proteins, and glucose (sugar), in the blood to determine the current status of the kidneys
How is nephrotic syndrome investigated?
urine ACR
Acute renal screen
How is nephritic syndrome managed?
urgent renal referral
BP control +/- diuresis
treat underlying cause once confirmed on biopsy
How is nephrotic syndrome managed?
dependent on the underlying cause often - BP management - diuresis - prophylaxis against VTE
aim to reduce proteinuria
What is balanitis?
inflammation of the glans penis which can result from infection, trauma or be premalignant as well as from some form of dermatitis/psoriasis
how does balanitis present?
penile soreness/itch
dysuria and dyspareunia
redness and swelling of glans penis
inability to retract/ lightening foreskin
meatal stensis - suggests lichens sclerosis
bleeding from foreskin/ odour
How is balanitis investigated?
male genitalia exam
consider STI screen
HbA1c to assess diabetes or underlying HIV
can perform sub-preputial swab
How is balanitis managed?
dependent on cause
- if dermatitis = give topical hydrocortisone
- if candidal = imidazole cream
- if bacterial = oral flucloxacilin - clarithromycin if contraindicated
- anaerobic causes = metronidazole
How does prostatitis present?
UTI like symptoms = dysuria, frequency & urgency lower back pain pain on ejaculation fever tachycardia perineal, penile or rectal pain
How is prostatitis investigated?
abdo/genitalia and rectal examination
MSU sample for dipstick to check for infection
Bloods - FBC (PSA)
Consider STI screen
How is prostatitis managed?
oral ciprofloxacin for 14days or Levofloxacin
advise analgesia for pain and fevers
advise adequate hydration
follow up after 48hrs and review in 14 days
emergency admission if…
- unable to take oral Abx
- severe symptoms or septic signs
- Diabetic or have a serious urological condition
What does epididymitis present with?
swollen, red or warm scrotum testicular pain and tenderness dysuria, urgency and frequency penile discharge lower abdo/pelvic pain blood in semen
How would epididymitis be investigated?
abdo and genitalia examinations
Bloods - FBC, CRP, ESR
consider STI screen
US to rule out testicular torsion
How is epididymitis managed?
unknown organism = ceftriaxone 1g IM plus oral doxycycline BD 10-14days OR oral orfloxacin BD 14/7
Chlamydia organism = oral Doxycyline BD for 10-14/7
or oral orfloxacin BD 14days
Enteric organism (E.Coli) = Orfloxacin BD 14/7 OR levofloxacin PO BD 10 days
advise - bedrest, scrotal elevation, cold packs, analgesia, supportive underwear
What does urethritis present like in men?
mucopurulent & purulent urethral discharge
itching/burning sensation near the opening of the penis
presence of blood in semen
penile irritation/ discomfort
What does urethritis present like in women?
frequent discomfort and burning sensation
abnormal discharge
What investigations should be done for suspected urethritis?
genitalia/abdominal examinations
urine samples or swabs may be taken
blood tests for infection/screen for UTI
How is urethritis managed?
usually antibiotics including doxycycline, azithromycin or orfloxacin
analgesia
STI notification and contact tracing - sexual abstinence
What does pylonephritis ?
main triad:
unilateral flank/loin pain
nausea and vomiting
fever
other presentations
- new myalgia/flu-like symptoms
- tenderness in ribs/flanks
How can we investigate pylonephritis?
MSU/CSU - determine infecting organism
dipstick - nitrites and leukocytes
abdo examination
How is pylonephritis managed?
offer antibiotics - cefalexin first line
others include co-amoxiclav, trimethoprim or ciprofloxacin (based on sensitivities)
analgesia
avoid dehydration & advise keeping hydrated
reassess in 48hrs for effectiveness of antibiotics
septic signs - hospital admission
How does urinary incontinence present?
occasional, minor leaks of urine usually when doing some form of activity sudden urge to urinate strain to pass, intermittent stream feeling incomplete passing of urine
How is urinary incontinence investigated?
perform a general examination - check weight, gait, neurological disease
pelvic examination - check for any prolapse and check pelvic muscle tone bimanually
urinalysis - check for any infection
post-voidal residue - catheter or US used to check how much urine retained in bladder after voiding
How is urinary incontinence managed?
- lifestyle advice - reducing caffeine, fluid intake, weight loss and smoking cessation
- behavioural techniques - bladder training (delaying urge) and scheduling toilet trips
- offer referral for 3 months of supervise pelvic floor muscle training
- consider Absorbent containment products, hand-held urinals, and toileting aids
- conservative Tx fails = refer to special urologist, urogynaecologist
- offer duloxetine as 2nd line (anti-depressant)
for UUI - offer oxybutynin, tolterodine/darifenacin as 1st line OR mirabegron if other contraindicated
What does cryptorchidism presented with?
testicular asymmetry
scrotal hyperplasia or asymmetry
How is cryptorchidism investigated/examined?
usually diagnosed with clinical examination
sometimes US used if clinician is unsure
How is cryptorchidism managed?
suspected undescended testes in dependent on the location & presence of testes
specialist management - includes surgical Tx/hormonal Tx
What does the varicocele present?
painless swelling - usually on left side
feels like a ‘bag of worms’
sometimes scrotal groin pain
ages in 12yrs +
Disappears on lying and reappears on standing.
What does the hydrocele present?
fluctuant, ovoid swelling enveloping the testis
may experience some discomfort/heaviness
common in neonates
How are varicoceles investigated/examined?
usually clinical diagnosis
US with colour flow
Doppler semen analysis
How are hydroceles investigated?
blood urine tests
US
transillumination
How is varicocele managed?
Subclinical or grade I varicocele - no Tx necessary
Grade II/III and asymmetrical testes - Observe with annual examinations
offer semen analysis if fertility is a concern
Grade II/III or symptomatic varicocele and abnormal semen parameters - refer to urologist for possible surgery
How does Urothialiasis present?
pain in lower abdomen or groin pain in testicles for males high temperature severe pain that comes and goes and sweating nausea and vomiting haematuria
How is urolithiasis investigated?
blood tests - calcium/uric acid
urine testing
imaging CT, abdo, x-rays US
analysis of passed stones
What does management of urolithiasis involve?
Conservative - watchful waiting to see if there is spontaneous passing of stones
medical management - alpha-blockers (tamsulosin) & NSAIDs for pain
Surgical management - shockwave lithotripsy - to break stone down into fragments making it easier to pass
What does paraphimosis involve?
A condition affecting males who are uncircumcised - foreskin which can no longer be pulled forward - becomes stuck and swollen
How does paraphimosis present?
inability to return the foreskin back to its normal position
foreskin has become swollen and painful
tip of penis may become discoloured = (dark red/blue) due to lack of blood flow
How is the paraphimosis managed?
treatment varies depending on age or severity
- treat/reduce the swelling by applying ice packs, bandaging tightly around the area
- needles to drain any pus/blood
- inject hyaluronidase
- analgesia for pain - may give anaesthetic/nerve block or oral narcotic
severe cases require complete circumcision
What is testicular torsion?
The twisting of the spermatic cord which is responsible for blood supply to the scrotum
How does testicular torsion present?
Sudden, severe scrotal pain swelling of the scrotum abdo pain nausea & vomiting testicle positioned higher than normal/unusual angle frequent urination fever
what are the investigations for testicular torsion?
urine test
scrotal US
How is testicular torsion managed?
if suspected admit immediately to urology or paediatric surgery
distortion is required within 4-8hours to avoid any ischemic damage
What is urinary retention and what causes it?
a condition where you cannot empty your bladder and so urine is retained
many causes usually categorised as obstructive/non-obstructive
- prostate cancer/BPH
- urethral stricture
- severe constipation
- pelvic tumour
- perineal pain
- drugs - antimuscarinics, opioid analgesics and anaesthetics
How is urinary retention investigated?
measure serum creatinine and eGFR
PSA testing if indicated
Abdominal examination may show abnormal palpation/percussion
How is acute urinary retention managed?
insert urethral catheter and discuss how the UR should be treated/managed
- alpha-blcokers - 65yrs+ which is started 24hrs prior to catheter removal and used until several hours of normal voiding is established
- intermittent urethral catheterization
- Long term indwelling catheter
How is chronic urinary retention managed?
- exclude any non-obstructive causes of reduced urine flow
- check serum creatinine
- refer for specialist assessment - arrange imaging
management options
- no catheterization - regular monitoring of renal function, volume of retention & imaging
- intermittent catheterization
- permanent indwelling catheter
- surgery to divert urine externally
What is the most common form of Glomerulonephritis?
membranous glomerulonephritis - autoantibody damage to the GBM - increasing permeability and allowing leakage of protein
How does membranous Glomerulonephritis present?
Nephrotic syndrome - proteinuria, Hypoalbuminemia, oedema
Investigations for Membranous Glomerulonephritis
Electron microscopy - thickened GBM, ‘spike & dome’ appearance, effacement of foot processes
Immunofluorescence - granular appearance
Mx of membranous Glomerulonephritis?
treat underlying cause
All pts = ACEi/ARB
immunosuppression = steroids and cyclophosphamides
How does membranoproliferative glomerulonephritis?
Usually present as nephrotic - proteinuria, hypoalbuminemia and oedema
Ix of membranoproliferative glomerulonephritis?
light microscopy - tram-track appearance
immunofluorescence - granular appearance
electron microscopy of renal biopsy = ‘dense deposits’
mx of membranoproliferative glomerulonephritis?
steroids are usually effective
What is rapidly progressive glomerulonephritis?
GBM breaks down as a result of proliferation and deposition of crescent shaped cells
how does rapidly progressive glomerulonephritis present?
nephritic syndrome
- haematuria
- oliguria
- azotemia
- HTN
- rapid loss renal function/GFR
Ix of Rapidly progressive glomerulonephritis?
light microscopy - crescent shaped cells in the glomeruli
immunofluorescence
type 1 - linear
type 2 - granular
type 3 - negative
mx of rapidly progressive glomerulonephritis?
immunosupressants - prednisolone & cyclophosphamide
plasmapheresis in some cases - goodpasture’s
What is post-streptococcal glomerulonephritis?
inflammation resulting from a streptococcal infection - Group B haemolytic strep
typically in children - ~6weeks after skin infection/impetigo
1-2 weeks after pharyngitis
How does post-streptococcal glomerulonephritis present?
nephritic syndrome
- visible haematuria
- oliguria
- peripheral & periorbital oedema
- malaise and headaches
- HTN
Ix for post-streptococcal glomerulonephritis?
light microscopy - glomeruli appear enlarged and hypercellular
electron microscopy - deposits in the subepithelium appear as humps
Immunofluorescence - granular or ‘starry sky’ appearance
bloods - Anti-DNAse B, raised ASO titre and decreased complement levels
Mx for post-streptococcal glomerulonephritis?
usually supportive mx
complications of post-streptococcal glomerulonephritis
some children can go onto developing renal failure
1/4 of adults have rapidly progressive GN
What is focal segmental glomerulosclerosis?
FSGS typically develops in young adults causing nephrotic syndrome and kidney disease
How does FSGS present?
foamy urine - loss of albumin via urine
hypoalbuminaemia
oedema
decline in kidney function
hyperlipidemia and lipiduria
drop in RBC - anaemia
How is FSGS Investigated/diagnosed?
urinalysis - increased protein/lipid
blood test - drop in RBC, lipids and protein
kidney biopsy - scarring and ‘glassy appearance’
light microscopy - segmental sclerosis and hyalinosis
Mx of FSGS?
dietary salt restrictions and diuretics (tx oedema)
steroids +/- immunosupressants
antihypertensives & statins & lifestyle changes
if secondary - tx of underlying cause
When Is renal replacement therapy considered?
CKD developing renal failure with GFR <15ml/min
What types of RRT are there and what do they involve?
- HAEMODIALYSIS - most common, 3x week, 3-5hr sessions, arteriovenous fistula surgery required 8 weeks prior to starting
- PERITONEAL DIALYSIS - dialysis solution (high dose dextrose) injected through permanent catheter
- RENAL TRANSPLANTATION - average wait 3yrs, renal vessels connected to external iliac vessels, lifelong immunosuppression to prevent rejection
What is IgA nephropathy?
Presentation?
commonest cause og Glomerulonephritis, presenting usually in childhood during a URTI/GI infection
young males, macroscopic haematuria,
hx of resp tract infection
rarer - proteinuria in nephrotic range, renal failure
- Henloch-schnolein purpura presents similarly but will manifest in the skin, connective tissue, joints and GI tract
Ix of IgA Nephropathy?
Light microscopy - mesangial proliferation
Electron microscopy - immune deposits of mesangium
Immunofluorescence - presence of immune complexes
Management of IgA nephropathy?
isolated haemturia/minimal proteinuria & normal GFR = no tx needed, Follow up and check renal function
Persistent haematuria & slight drop in GFR = ACEi
Active disease - declining GFR & unresponsive to ACEi = immunosupression with costicosteroids
What is Minimal change disease?
Presentation?
most common cause of nephrotic syndrome in children
Presentation
- nephrotic syndrome - proteinuria
- normal renal function
- normal level of complement
- normotensive
Ix and finidngs for Minimal change disease?
Light micrscopy - normal glomeruli, ‘minimal change’
Electron microscopy - fused podocytes and effacement of foot processes
Immunofluorescence = negative, change isn’t due to immune complexes
Mx of minimal change disease?
usually steroids responsive
if steroids resistant - cyclophosphamide
What is polycystic Kidney disease?
A commonly inherited kidney disease - cysts on kidneys
presentation of PKD?
most commonly presents with loin pain HTN bilateral kidney enlargement gross haematuria following trauma UTI/Pyelonephritis intracranial (berry) aneurysms
How is PKD investiagted?
Diagnosis?
Bloods - FBC, U&E, creatinine and eGFR, bone profile
Urinanalysis and urine MC&S
Imaging - US/CT
aged <30 - uni/bilateral 2 cysts
aged 30-59 - 2 cysts bilaterally
>60 - 4 cysts bilaterally
Management of PKD?
tolvaptan - slows progression of cyst development
monitoring RFs/exacerbations
supportive management
