Renal pathology Flashcards
lower UTI symptoms ?
- dysuria
- frequency
- urgency
- pain/stinging
- incontinence
- confusion
but can often be asymptomatic
upper tract UTI symptoms ?
- loin pain
- fever
- rigors
- haematuria
- looks more unwell
- vomiting
- anorexia
- costovertebral pain
what counts as uncomplicated UTI ? what complicated ?
it is in a non-pregnant women, everything else is complicated
- pregnant, men, catheter, abnormal anatomy, children, immunocompromised
UTI aetiology ? most common ?
- E. coli (most common)
- staphylococcus
- candida albicans
what is is seen on urine dip in UTI ?
- nitrites (gram -ve bacteria break down nitrates => nitrites)
- leukocytes
what are casts found in urine ?
found on urine microscopy
- casts are made of RBC, WBC, kidney cells, protein, fat
- give clue to renal pathology
- should be that many
when treat asymptomatic bacteriuria? what age do you not ?
- if >65 then do not treat
- treat in pregnancy
uncomplicated UTI Mx ?
3 days Abx (nitrofuartoin)
immunocompromised women UTI Mx ?
5-10 days Abx (Nitro)
men, pregnant women, catheter UTI Mx ?
7 days Abx (nitro)
what Abx to avoid during pregnancy ?
avoid trimethoprim in 1st tri
avoid nitrofurantoin in 3rd
Mx of pyelonephritis ? duration of treatment ?
- fluid replacement
- IV Abx (co-amoxiclav)
- drain obstructed kidney
- catheter
- analgesia (paracetamol or codeine phosphate)
- 7-14 Abx days depending on Abx
what counts as recurrent UTIs ?
> 2 in 6 months
3 in 1 yr
What is pyelonephritis ?
infection of the renal parenchyma and soft tissues of renal pelvis/upper ureter
pyelonephritis complications ?
associated with significant sepsis + systemic upset
what is urethritis ?
sexually transmitted disease
- acute urethral discharge following unprotected sex
urethritis aetiology ?
usually Neisseria gonorrhoea (gonococcal)
or chlamydia trachiomatis (non-gonococcal)
urethritis RF ?
- new sexual partner
- multiple sexual partners
- <25
urethritis presentation ?
- dysuria
- urethral discharge
- pruritus at end of urethra (itch skin)
urethritis Ix ?
- urinalysis (leukocyte esterase + ve)
- sediment of first voided urine (high WBC)
- gram stain of urethral discharge (high WCC)
urethritis Mx ? depends on what ?
depends if gonorrhoea or not
- cephalosporin (gonorrhoea)
- azithromycin (not)
urethritis complication ?
- high mortality in untreated women (10-40%)
- untreated may cause: arthritis meningitis, endocarditis, infertility
What is acute prostatitis ?
painful inflammation within the prostate usually plus recent or ongoing infection
- most frequent urological diagnosis in men <50 yrs
acute prostatic aetiology ?
commonly caused by E.Coli (from UTIs)
- in rare cases can be complication of urethritis (STI)
acute prostatic presentation ? (4)
- acute LUTS onset (dysuria, frequency, perineal discomfort)
- systemic signs (fever, chills, malaise)
- extreme lower abdo/ejaculatory/rectal pain
- tender prostate
acute prostatitis Ix ?
- urinalysis (leukocytes, bacteria)
- urine culture (bacteria)
- culture of prostatic secretions (bacteria +ve)
- blood cultures (identify organism)
acute prostatitis Mx ?
treat with Abx (prolonged course often required if chronic prostatitis follows)
- analgesia (NSAIDs)
acute prostatitis complications ? (3)
- develop to chronic prostatis
- sepsis
- urinary retention
what is cystitis ?
it is a chronic condition causing inflam in the bladder => LUTS + suprapubic pain
cystitis Presentaiton ?
similar to LUTI but more persistent (sig impact on QOL + mental health)
- >6 weeks suprapubic pain, frequency, urgency, worse during menstruation
cystitis Mx ? (3)
- supportive mx: avoid alcohol/caffeine, stop smoking, pelvic floor exercises, bladder retraining, CBT
- oral meds: analgesia, antihistamines
- surgical: botulinum toxin injections during cystosocpoy
what is AKI ? what measurements ? (3)
acute decline in kidney function (=> increase serum creatinine and/or reduced UO)
- rise in creatinine > 26 mmol/L within 48 hrs
- rise in creatinine > 1.5 x baseline within 7 days
- urine output < 0.5 mL/kg/h for > 6 hrs
what can the aetiology of AKI be divided into ?
- pre-renal
- intrinsic kidney failure
- post-renal
name pre-renal causes of AKI ?
due to reduced renal perfusion
- low vascular volume (hypovolaemia, haemorrhage)
- low CO
- systemic vasodilation (sepsis)
- renal vasoconstriction
- overdiueresis
- HF
name renal causes of AKI ?
intrinsic kidney failure
- acute tubular necrosis
- glomerulonephritis
- interstitial nephritis
name post-renal causes of AKI ?
due to obstruction to urine
- urolithiasis
what is the physiology when there is reduced perfusion to the kidney ?
reduced perfusion => reduced perfusion pressure => increase Na + water reabsorption
- casocontrction of glomerular effect arteriole and dilation of afferent => maintain glomerular filtration
- reduced perfusion => RAAS activation + ADH release =>concentration urine
AKI RF ? (9)
- age > 65
- underlying KD
- diabetes
- sepsis
- iodinated contrast
- nephrotoxins (NSAIDs, ACEI)
- fluid loss (excessive)
- haemorrhage
- drug overdose
overall AKI Mx ?
- avoid nephrotoxic meds
- adequate fluid intake: fluid hydration (but be careful in HF)
- treat underling cause (stones)
what drugs should be avoided in AKI ?
stop the DAMN drugs
- Diuretics
- ACEI/ARBs
- Metformin
- NSAIDs
AKI complications ?
- hyperkaklemiea
- fluid overload
- HF
- pulmonary oedema
- uraemia (=> encephalopathy)
what blood gas would be found in AKI ?
- metabolic acidosis (kidney not producing as much bicarb)
What is CKD ?
abnormal structure or function for more than 3 months with implications for health
what values indicate CKD ?
abnormal function: eGFR <60ml/min or albuminaemia (urine ACR > 3mg/mmol)
what is creatinine ? why good to measure for kidney disease ?
measure creatinine (waste product of muscle metabolism - directly proportional to muscle mass), purely excreted by kidney so measure of kidney function
most common causes of CKD ? (3)
- diabetes
- glomerulonephritis
- HTN/renovascular disease
CKD presentation ?
usually asymptomattic
- fatigue
- oedema
- nausea
what is used to stage CKD ?
- GFR
- ACR
to stage and work out prognosis ( bad = low GFR, high ACR)
how is CKD diagnosed ?
> 3 months (documented or inferred)
- eGFR < 60ml/min
- ACR > 3 mg/mmol
(so need blood and urine test)
what is the general Mx of CKD ?
slow progression
- BP control (use ACEI/ARB)
- avoid nephrotoxins
- treat underlying disease
- anaemia
- stop smoking
what is renal replacement therapy ? what does it not do ?
RRT: removes excess water = salt + electrolytes and waste products
- but does not activate vit D or produce EPO
in what CKD patients should transplant be considered ?
G5 patients
what are contraindications to transplant in CKD patients ?
- cancer with mets
- active infections
- unstable CVD
CKD complications ?
- CKD is RF for CVD
- all-cause mortality
- AKI
how often should you monitor renal function in CKD ?
monitor GFR + ACR at least annually according to risk
- if high risk, monitor every 6 months
- if v high risk, monitor every 3-4 months
how does CKD affect serum phosphate and vit D levels ?
CKD => high serum phosphate + low hydroxylation of vit D by the kidney
what is glomerulonephritis ?
umbrella term: for inflammation + damage of the glomerulus (filters of the kidney) can be acute or chronic
generally what is nephrosis and nephritis ?
nephrotic: proteinurea due to pdocyte pathology
- nephritis: haematuria due to inflam damage
what is podocyte involvement in glomerulopnephritis ?
podocytes lay key role in glomerular filtration barrier (absence => protein in urine)
what does glomeruli nephritis cause ?
- reduced renal efficiency
- causes protein + RBC to leak form blood into urine
- high BP (flame haemorrhages in eye, heart hypertrophy)
what is nephritis syndrome ? main symptoms ?
group of symptoms (not diagnosis) suggests kidney inflam
- haematuria (micro or macroscopic)
- oliguria (reduced UO)
- proteinurea
- fluid retention
- red cell cast on ruine microscopy
Mx of most types of glomerulonephritis ?
- immunosuppression (steroids)
- BP control by blocking RAAS (ACEI), like in CKD Mx
causes of nephritic syndrome ? (4) commonest cause
- IgA nephropathy (most common)
- HSP
- post strep glomerulonephritis
- Anti-GBM disease (good pastures)
what is IgA nephropathy / pathophys ? another name for it ? nephritic or nephrotic ?
Bergers disease - nephritic
AgI gets glycosylated (sugars stick to it) => when moves through kidney gets deposited => inflammation + scarring (nephritis)
what can trigger IgA nephropathy ?
often developed after URTI of gastroenteritis
how is IgA nephropathy diagnosed ?
kidney biopsy for diagnosis (mesangial IgA deposits + glomerular mesangial proliferation)
IgA nephropathy Mx ?
- control BP (ACEI, ARB), RAAS inhibitors to reduce proteinurea
- oral prednisolone if bad
what is post strep glomerulonephritis ? time course
occurs 1-3 weeks after a beta haemolytic streptococcus infection (like tonsillitis)
immune complexes (streptococcal antigens, Abs + compliment proteins) get stuck in glomeruli => kidney inflam
post strep glomerulonephritis presentation ?
(nephritic syndrome)
- haematuria
- oedema (sign of severe of chronic disease)
- HTN
- oliguria
post strep glomerulonephritis diagnosis ?
diagnosis: renal biopsy for definitive Dx
- blood would show nephritic pic
- evidence of strep infection
post strep glomerulonephritis Mx ?
80% make full recovery
- if worsening renal function: anti-HTN (dietetic)
- main way to prevent PSGN is to prevent strep infection
what is anti GBM disease ? also known as ? nephritic or nephrotic ?
good pastures (nephritic syndrome)
- rare autoimmune
- pulmonary- renal condition characterised by anti glomerular basement membrane antibody
describe anti GBM disease pathosphsy ?
autoantibodies to alpha 3 chain in type IV collagen (found in alveoli + glomerular BM)
- causes glomerular nephritis and pulmonary haemorrhage
if patient present with renal failure and haemoptysis what should you consider ? (2)
- goodpastures (anti-GBM)
- granulomatosis with polyangitis
anti GBM disease presentation ?
- renal disease (oligo/anurea, haematuria, AKI)
- lung disease (pulmonary haemorrhage (=> SOB, haemoptysis)
anti GBM disease Ix ?
- anti-GBM antibody titre (=ve)
- renal biopsy (IgG staining)
anti GBM disease Mx ?
plasma exchange
- corticosteroids (prednisolone)
- cyclophosphamide
what are the primary causes of nephrotic syndrome ? (4)
- minimal change disease
- focal segmental glomerulosclerosis
- membranous nephropathy
- membranoproliferative GN
what is nephrotic syndrome ? triad ?
kidney disorder that causes your body to pass too much protein in urine (BM becomes highly permeable to protein)
- proteinurea
- hypoalbumaemia
- peripheral oedema
nephrotic syndrome presentation ?
- frothy urine
- generalised oedema
- Pallor
what does nephrotic predispose to ? complications
- thrombosis (due to increased clotting factors)
- infection (due to Ig loss)
- hypertension
- high cholesterol
what would be found on investigation of nephrotic syndrome ?
classic triad: low serum albumin, high urine protein, oedema
- deranged lipid proflie
- high BP
- hypercoagulabilty
- haematuria usually absent
nephrotic syndrome mx ?
- reduce oedema (fluid + salt restriction, diuretics - furo)
- treat underlying cause (renal biopsy)
- reduce proteinuria and BP (ACEI/ARB)
- complications (VTE prophylaxis, avoid infection)
most common nephrotic syndrome in children ? adults ?
children: minimal change disease (idiopathic)
- adults: focal segmental glomerulosclerosis
what is minimal change disease ?
most common cause of nephrotic syndrome in kids
- characterised by heavy proteinuria, oedema, hypoalbuminaemia, hyperlipidaemia
- has minimal histological changes in kidney (hence name) (mild mesangial proliferation)
minimal change disease aetiology ?
- mostly idiopathic
- secondary to HL, leukaemia, hep B/C infection
minmal change disease Ix ?
biopsy appears normal but fused podocytes on electron microscopy
- diagnosis usually made on clinical grounds
minmal change disease Mx ?
nephrotic syndrome
- high dose steroids (prednisolone), 4 - 16 weeks
- low sal diet
- dieretic (for oedema)
- albumin infusions (if severe hypoalbuminaemia)
what is focal segmental glomerulosclerosis ?
(nephrotic syndrome)
- injury to podocytes in renal glomeruli which can lead to nephrotic syndrome
focal segmental glomerulosclerosis RF ? (4)
- male
- FSGS FHx
- HIV
- obesity
focal segmental glomerulosclerosis Ix ? diagnostic ?
- dx: biopsy ( glomeruli have scarring of certain segments - focal sclerosis)
- nephrotic picture
focal segmental glomerulosclerosis Mx ?
- corticosteroids, ACEI, low salt diet
- if secondary cause then treat underlying cause
what is membranous nephropathy ?
(nephrotic syndrome)
chronic immunologically mediated glomerular BM disease that can resolve spontaneously
- can have stable real function or progress to end stage renal failure
membranous nephropathy pathophys ?
thickening of glomerular capillary wall, IgG + compliment deposit in sub epithelial surface which causes leaky glomerulus
(link with malignancy)
Membranous Malignancy
membranous nephropathy aetiology ?
(nephrotic syndrome)
- Malignancy (M-M, membranous malignancy)
- autoimmune conditions, viruses, drugs, tumours
membranous nephropathy Ix ?
idiopathic diagnosis should only be made after secondary causes excluded
- serum PLA2R Ab, renal biopsy (definitive)
membranous nephropathy Mx ?
low risk: control oedema, HTN, hyperlipidaemia, proteinurea
- higher risk: prednisolone
what is the commonest case of end stage renal failure ?
diabetic nephropathy
how does DM affect kidneys ?
hyperglycaemia => RAAS activation, oxidative stress => increase glomerular capillary pressure + podocyte + endothelial dysfunction => reduced renal function
(worsened be co-existing HTN)
HUS triad ?
triad px: haemolytic anaemia, low platelets, AKI
(with haematuria/proteinurea)
what is rhabdomyolysis ? pathophys
results from skeletal muscle breakdown => release of intracellular contents (K+, myoglobin) into extracellular space
rhabdomyolysis Dx ? Ix ?
- serum myoglobin
- plasma CK > 5 times upper limit
rhabdomyolysis Mx ? (3)
- supportive
- urgent hyperkalaemia mx
- IV fluid rehydration
what is polycystic kidney disease ?
it is a genetic condition where kidney develop multiple fluid filled cysts => significantly impaired kidney function
- also associated with haptic + cerebral aneurysms
what are the two types of polycystic kidney disease ? who affected by both ?
- adults: autosomal dominant (more common), 2/3 require renal replacement
- babies: autosomal recessive (presenta antenatally)
(progressive renal failure by around 50)
polycystic kidney disease signs ? (5)
- HTN
- haematuria
- polyuria
- abdo/loin pain
- palpable masses
dominant polycystic kidney disease mx ?
tolvaptan (slow progression to renal failure)
- antihypertensives, analgesia
- increased daily water intake
what are nephrolithiasis ?
president of crystallin stones (calculi) in urinary system (kidneys + ureter)
- usually originate in collecting duct and deposit from renal pelvis => urethra
what are the constituents of urinary stones ?
urinary constituents
- calcium oxalate
- calcium phosphate
- urate
urinary stones RF ?
- chronic dehydration
- diet (high NaCl)
- obesity
- meds
- male
urinary stones px ?
often asymptomatic, acute renal colic pain (severe), loin pain, UTI symptoms
- usually always UNI-lateral
urinary stones Ix ?
NC-CT KUB
- urinalysis
urinary stones Mx ? depends on what ?
depends on size, location, composition
- analgesia (IV NSAID, opiates)
- stone < 5mm in lower ureter: pass spontaneously, increase fluid intake
- stone: > 5mm/ medical or procedure
urinary stones mx when stone > 5mm ??
- try medical expulsion: nifedipine or tamsulosin
- if fails: try extracorporeal shock wave lithotripsy (ESWL)
- if obstruction of infected: ureteric Sten
urinary stone complication ?
always remember sepsis
- infected obstructed kidneys can kill, need to drain so methods of drainage: ureteric stent, nephrostomy
what is obstructive uropathy ? lead to what ?
it is blockage preventing ruine flow through ureters, bladder + urethra => build up of urine => back pressure up to kidneys => impaired kidney function (post renal AKI)
what is vesicoretertic reflux ?
VUR is urine refluxing from bladder back into ureters
obstructive uropathy px ?
- upper urinary tract: loin to groin flank pain, low urine output, impaired renal function on blood tests (raised creatinine)
- lower: difficulty to pass urine, urinary retention, impaired renal function on blood tests
common causes of obstructive uropathy ? upper ? lower ?
- upper: kidney stones, tumours, ureter strictures (scar tissue), retroperitoneal fibrosis, bladder cancer
- lower: BPH, prostate/bladder cancer, urethral structures
obstructive uropathy Dx ?
ultrasound
obstructive uropathy mx ?
remove or bypass the obstruction
- nephrostomy to bypass obsturciotn of upper UT, or ureteric stent
- lower: urethral catheter
if cause of obstructive uropathy is prostatic obsturciotn, what is the mx ?
star alpha blocker (tamulosin)
obstructed infected kidney Mx ?
initial: ABCDE, sepsi screen, fluid resus, start Abx, CT KUB
- temporary treatment for draining uninfected obstructed kidney: ureteric Sten 9performed in theatre), nephrostomy (tube that passes through skin)
what is benign prostatic hyperplasia (BPH) ? which area of prostate ?
increase in epithelial + stroll cell numbers in periurethral area of prostate (due to increase in cell number of reduced apoptosis or both)
- prostate transition zone
what is the static and dynamic component of BPH ?
- static component: increase benign prostatic tissue => narrowing of urethral lumen => LUTS
- dynamic component: increase prostatic smooth muscle (alpha adrenergic mediated) => LUTS
link between androgens and BPH ?
androgens do not cause BPE but required (androgen withdrawal => partial involution)
BPH Px ?
LUTS: hesitancy, weak flow, urgency, frequency, intermittency, straining, terminal dribbling, incomplete emptying (=> chronic retention), nocturia, haematuria
what scoring system can be used to assess severity of LUTS ?
international prostate symptoms score (IPSS)
what is done on assessment for BPH ?
- DRE (assess size, shape, characteristics of prostate)
- abdo exam
- urinary frequency volume chart
- urine dipstick
- prostate specific antigen
what conditions can cause a raised PSA ?
- prostate cancer
- BPH
- prostatic
- UTI
- recent ejaculation
- cycling
BPH mild symptoms Mx ?
no interventions
BPH medical option ? how do they work ?
- alpha blockers (tamsulosin): relax smooth muscle (quick response)
- 5-alpha redacts inhibits (finasteride): dihydrotestostone: reduce size of glandular prostate)
what is something that the patient needs to know about finasteride ?
excreted in semen so need to use condoms
BPH surgical options ?
transurethral resection of the prostate (TURP): remove part of the prostate from inside the urethra
TURP side effects ?
- bleeding
- infection
- urinary incontinence
- ED
- retrograde ejaculation
when to refer for 2WW for prostate cancer ?
if aged >45 and have:
- unexplained visible haematuria w/o UTI
- visible haematuria that persist after successful UTI tx
>60 and have unexplained non-viable haematurea AND dysurea of high WCC on bloods
most common aetiology of prostate cancer ?
most are: adenocarcinoma that occurs in peripheral part of prostate => spreads locally through prostate capsule (seminal vesicles, peri-prostatic tissue, bladder neck)
prostate cancer RF ?
- male
- > 50
- black ethnicity
- FHx
explain about the link between PSA and prostate cancer ?
can be elevated for many reasons
- 70% of men with raised PSA DONT have cancer
- 6% with cancer have normal PSA (not 100% sensitive)
what would be seen on DRE in prostate cancer ?
may show hard, irregular, modular, craggy prostate)
prostate cancer Dx ?
TRUS- guided, or MRI-TRUS fusion-guided (needed to confirm diagnosis)
what grading is used for prostate cancer ? describe a bit ?
Gleason grading (guides mx)
1 (normal) - 5 (high grade)
- high grade more likely to metastasis and spread
when do treatment for prostate cancer ?
- if < 70 + symptomatic: surgery (radical prostatectomy)
- if > 70 + mild symptoms: consider hormone therapy or active surveillance
what is the commonest cancer in men 20 - 45 ? prognosis ?
testicular cancer
- highly curable (early diagnosis)
testicular cancer presentation ?
hard, painless nodule on one testis (noticed by patient or on screening)
- non trans illuminable
- gynaecomastia
most common aetiology of testicular cancer ?
most are germ cell tumours (90%)
- pre cancerous lesion (carcinoma in situ) => leads to malignant growth
- characterised by growth of basement membrane => replace testicular parenchyma
what usually causes metastasis in testicular cancer ?
metastases usually caused by lymphatic spread (spermatic cord => lymph node - retroperitoneal)
testicular cancer RF ?
- undescended testes
- gonadel dysgenesis
- FHx of testicular cancer
- HIV infection
testicular cancer Ix ? what on the day ?
- scrotal USS to be done that day
- tumour markers
- CXR (to look for metastases to work out staging)
- CT (enlarged retroperitoneal lymph nodes
what tumour markers useful in testicular cancer ?
alpha fetoprotein and bHCG are useful tumour markers + help monitor treatment
testicular cancer Mx ?
most curable cancer, extremely sensitive to chemo
- initially start with radical orchiectomy to confirm histological dx
- retroperitoneal lymph bode dissection (to debulk residual LB masses after chemo)
radical orchiectomy complications ?
infertility (also risk associate with chemo - done in mx of testicular cancer)
renal cell carcinoma - what is it ? most common aetiology ?
renal cell carcinoma (adenocarcinoma)
- common, found incidentally half the time (accounts of 90% real cx)
where does most renal cell carcinoma arise ?
proximal renal tubular epithelium
renal cell carcinoma symptoms ? classic triad ?
60 - 70 yo
- 50% found incidentally
- *haematuria
- *loin pain
- *abdominal mass
- anorexia
- <10% present with classic triad, most found incidentally on imaging
renal cell carcinoma RF ? (5)
- 15% of haemodialysis patients develop RCC
- smoking
- HTN
- obesity
- age
renal cell carcinoma Ix ?
- imaging: US, CT/MRI
renal cell carcinoma mx ?
- radical nephrectomy
- RCC is generally radio + chemo resistant
bladder cancer - most common etiological subtypes ?
cancer in the bladder arises from endothelial lignin (urothelium)
- transitional cell carcinoma (90%)
- SCC (5%)
- adenocarcinoma
bladder cancer px ?
- painless haematruia
- recurrent UTIs
- voiding irritability
bladder cancer Ix ? dx ?
- flexible or rigid cystoscopy + biopsy (diagnostic)
- CT urogram (dx and provides staging)
bladder cancer Mx ?
- transurethral resection of bladder rumour (TURBIT) (non-muscle invasive)
- incravesical chemo (after TURBIT to reduced risk of recurrence)
- radiotherapy
what is neuropathic ladder ?
dysfunction due to damage to innervation
what is urinary incontinence ? how is it classified ? (4)
involuntary loss of urine F:M (2:1)
- classified: urgency, stress, mixed, overflow, continuous
causes of incontinence in men ? (2)
- prostate enlargement
- TURP
what is stress incontinence ?
involuntary loss of urine during activities that increase intra abdominal pressure ( crying, laughing) + incompetent sphincter
stress incontence Mx ? different approaches ?
- conservative: lifestyle (no alcohol, caffeine, weight loss, stop smoking), pelvic floor exercises
- Ring pessary may help uterine prolapse
- medical options: dulextine
describe the pelvic floor exercises for stress incontinence ?
8 contractions x 3/day for 3 months
what is urge incontinence ?
involuntary loss of urine proceed by urgency - idiopathic
(detrusor overactivity)
urge incontinence mx ? what medications ? (2)
- bladder training + weight loss
- antimuscarinic (oxybutynin)
- B-3 agonist (mirabegron) (inhibit detrusor contraction)
- botox (injected using cystoscope)
what can LUTS be divided into ?
storage symptoms
voiding symptoms
name some storage LUTS ? (5)
- frequency
- nocturia
- urgency
- urgency incontinence
- bedwetting (due to high pressure chronic retention)
name some voiding LUTS ? (6)
- hesitancy
- straining
- poor/intermittant stream
- incomplete empyting
- dribbling
- haematuria
common cause of voiding LUTS ? (4)
- BPE
- prostate cancer
- urethral stricture
- phimosis
common causes of storage LUTS ? (4)
- overactive bladder
- cystitis
- bladder tumour
- bladder calculi
what does circumcision reduce the risk of ? (2)
reduce risk of STIs and penile cancer
what is balantitis ? associated with what ?
acute inflammation of foreskin + glans, associated with strep + staph infection
balantitis RF ?
- diabetes
- young children with tight foreskins
balantitis mx ?
- abx
- circumcisoin
- hygiene advice
what is balantitis xerotican obliterates ? mx ?
(BXO - equivalent of niche sclerosis in women) => phimosis
- Mx: typical steroids, circumcision may be required
what is phimosis ?
foreskin occludes the meatus => balantitis + ballooning
phimosis px ?
in adulthood: painful intercourse, infection, ulceration
what is paraphimosis ? what does it lead to ?
irreplaceable retracted foreskin => prevent venous return => oedema + ischaemia of the glans
paraphimosis px ?
- retracted foreskin
- penile oedema
- possible discolouration (sign of ischaemia)
(common in catheterised)
paraphimosis Mx ? (3)
- ice method (apply topical lidocaine, wait 5 mins, apply ice wrapped in gauze - do no apply directly to skin)
- sugar method: apply granulated sugar or 50% dextrose (reduces swelling my osmosis)
- surgical: dorsal slit, circumcision
what is priapsim ? for how long ?
persistence unwanted erection > 4hrs in absence of sexual stimulation (ED)
what are the 3 types of priapism ? describe each a bit
- low flow (emergency) (ischaemic priapism caused bye venous occlusion)
- high flow (arterial priapsim => painless erection)
- recurrent (painful + self limiting but can progress to low flow)
low flow priapsim mx ? (2)
- aspirate penis
- alpha 1 adrenergic agonist (phenylephrine)
describe the physiology of an erection ? what innervation
- parasympathetic innervation (S2 - 4)
- arterial dilation, smooth muscle relaxation (by NO release) , corporeal vent occlusive mechanism
erectile dysfunction RF ?
- little exercise
- obesity
- smoking
- hypercholesterolaemia
- diabetes
- high alcohol intake
erectile dysfunction mx ?
- lifestyle modifications
- phosphodiesterase inhibitors
patient presents with a testicular lump - what is it ?
cancer until proven otherwise
patient present with acute, tender enlargement of testes. what is it ?
testicular torsion
what is epididymo-orchitis ? important Ddx ?
- inflammation of epididymis and orchitis is inflammation of testicle
- usually the result of infection
don’t forget torsion !
causes of epididymo-orchitis ?
infection depend on RF (sexually active)
- E.Coli (associated with UTI)
- if < 35: chlamydia, gonorrhoea
epididymo-orchitis px ?
gradual onset of minutes - hours with unilateral testicular pain
- dragging sensation in testicle
- swelling
- tenderness on palpation
- urethral discharge
- systemic symptoms
epididymo-orchitis ix ?
investigated for aetiology (enteric or STI)
- urine microscopy
- culture + sensitivity
- charcoal swabs
epididymo-orchitis mx ? (5)
IV Abx
- if low risk STI: ofloxacin
- if <35: duxcycline (covers chlamydia) if gonorrhoea suspected, add ceftriaxone
- analgesia (paracetamol)
- supportive underwear
- little physical activity
- abstain form sex
epididymo-orchitis complications ? (4)
- chronic pain
- chronic epididymitis
- testicular atrophy
- scrotal abscess
what is testicular torsion ? describe he anatomy ? why emergency ?
it is twitting of the spermatic cord with the rotation of the testicle (urological emergency)
- delay in treatment = > increase risk of ischaemi + necrosis of testicle => sub fertility or infertility
typical testicular torsion px ?
teenage boy, often triggered by sport
- acute rapid onset unilateral testicular pain
- abdo pain
- vomiting
- may radiate to back/loin
- may gave gad a self-resolving episode of groin pain
testicular torsion o/e ?
- firm swollen testicle
- elevated or retracted testicle
- absence of cremesteric reflex
- rotation
- high riding/transverse lie
testicular torsion mx ?
- NBM (in prep for surgery)
- analgesia
- urgent senior urogloy assessment
- surgical exploration of scrotum
- orchiopexy (fixation of the testes in the scrotum - bilaterally)
- orchidectomy (if necrosis to testicle)
what testicular pathologies with transilluminate with pen torch ?
- hydrocele
- spermatocele
what is hydrocele ?
collection of fluid within the tunica vaginalis
- tunica vaginalis is a sealed pouch of membrane that surround testes
hydrocele px ? (3)
- usually painless
- present with soft scrotal swelling
- transillumination
hydrocele o/e ?
-testicule palpable within hydrocele
- soft
- fluctuant
- large
hydrocele dx ?
clinical dx
- consider US
hydrocele mx ?
- if small: not much (just observe)
- if large or symptomatic: surgery, aspiration, sclerotherapy
what is varicocele ?
veins in pampiniform plexus become swollen
- can be uni or bilateral
- pampiniform plexus is venous plexus found in spermatic cord and drains the testes
- varicocele is a result of increases resistance
which side more commonly affected in varicocele ? why ? what could it indicate ?
L side more commonly affected
- L sided varicocele could indicated renal cx
- involvement of L renal vein => L spermatic vein obstruction => L sided varicocele (whereas R testicle drains directly to IVC)
varicocele px ?
throbbing/dull pain or discomfort
- worse on standing
- dragging
- bag of worms texture (more prominent on standing)
varicocele Ix ?
- US
- clinical Dx
varicocele Mx ?
ig pain, atrophy of infertility: surgery or endovascular embolisation
epididymal cyst px ?
usually asymptomattic
- may have a lump (fluctuant swellings)
epididymal cyst Ix ? o/e ?
- soft, round, separate from testicle, difficult to transilluminate
- dx may be confirmed with US
