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4 - Med > Renal pathology > Flashcards

Renal pathology Flashcards

1
Q

lower UTI symptoms ?

A
  • dysuria
  • frequency
  • urgency
  • pain/stinging
  • incontinence
  • confusion
    but can often be asymptomatic
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2
Q

upper tract UTI symptoms ?

A
  • loin pain
  • fever
  • rigors
  • haematuria
  • looks more unwell
  • vomiting
  • anorexia
  • costovertebral pain
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3
Q

what counts as uncomplicated UTI ? what complicated ?

A

it is in a non-pregnant women, everything else is complicated
- pregnant, men, catheter, abnormal anatomy, children, immunocompromised

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4
Q

UTI aetiology ? most common ?

A
  • E. coli (most common)
  • staphylococcus
  • candida albicans
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5
Q

what is is seen on urine dip in UTI ?

A
  • nitrites (gram -ve bacteria break down nitrates => nitrites)
  • leukocytes
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6
Q

what are casts found in urine ?

A

found on urine microscopy
- casts are made of RBC, WBC, kidney cells, protein, fat
- give clue to renal pathology
- should be that many

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7
Q

when treat asymptomatic bacteriuria

A

if >65 then do not treat

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8
Q

uncomplicated UTI Mx ?

A

3 days Abx (nitrofuartoin)

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9
Q

immunocompromised women UTI Mx ?

A

5-10 days Abx (Nitro)

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10
Q

men, pregnant women, catheter UTI Mx ?

A

7 days Abx (nitro)

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11
Q

what Abx to avoid during pregnancy ?

A

avoid trimethoprim in 1st tri
avoid nitrofurantoin in 3rd

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12
Q

Mx of pyelonephritis ? duration of treatment ?

A
  • fluid replacement
  • IV Abx (co-amoxiclav)
  • drain obstructed kidney
  • catheter
  • analgesia (paracetamol or codeine phosphate)
  • 7-14 Abx days depending on Abx
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13
Q

what counts as recurrent UTIs ?

A

> 2 in 6 months
3 in 1 yr

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14
Q

What is pyelonephritis ?

A

infection of the renal parenchyma and soft tissues of renal pelvis/upper ureter

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15
Q

pyelonephritis complications ?

A

associated with significant sepsis + systemic upset

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16
Q

what is urethritis ?

A

sexually transmitted disease
- acute urethral discharge following unprotected sex

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17
Q

urethritis aetiology ?

A

usually Neisseria gonorrhoea (gonococcal)
or chlamydia trachiomatis (non-gonococcal)

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18
Q

urethritis RF ?

A
  • new sexual partner
  • multiple sexual partners
  • <25
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19
Q

urethritis presentation ?

A
  • dysuria
  • urethral discharge
  • pruritus at end of urethra (itch skin)
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20
Q

urethritis Ix ?

A
  • urinalysis (leukocyte esterase + ve)
  • sediment of first voided urine (high WBC)
  • gram stain of urethral discharge (high WCC)
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21
Q

urethritis Mx ? depends on what ?

A

depends if gonorrhoea or not
- cephalosporin (gonorrhoea)
- azithromycin (not)

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22
Q

urethritis complication ?

A
  • high mortality in untreated women (10-40%)
  • untreated may cause: arthritis meningitis, endocarditis, infertility
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23
Q

What is acute prostatitis ?

A

painful inflammation within the prostate usually plus recent or ongoing infection
- most frequent urological diagnosis in men <50 yrs

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24
Q

acute prostatic aetiology ?

A

commonly caused by E.Coli (from UTIs)
- in rare cases can be complication of urethritis (STI)

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25
Q

acute prostatic presentation ? (4)

A
  • acute LUTS onset (dysuria, frequency, perineal discomfort)
  • systemic signs (fever, chills, malaise)
  • extreme lower abdo/ejaculatory/rectal pain
  • tender prostate
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26
Q

acute prostatitis Ix ?

A
  • urinalysis (leukocytes, bacteria)
  • urine culture (bacteria)
  • culture of prostatic secretions (bacteria +ve)
  • blood cultures (identify organism)
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27
Q

acute prostatitis Mx ?

A

treat with Abx (prolonged course often required if chronic prostatitis follows)
- analgesia (NSAIDs)

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28
Q

acute prostatitis complications ? (3)

A
  • develop to chronic prostatis
  • sepsis
  • urinary retention
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29
Q

what is cystitis ?

A

it is a chronic condition causing inflam in the bladder => LUTS + suprapubic pain

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30
Q

cystitis Presentaiton ?

A

similar to LUTI but more persistent (sig impact on QOL + mental health)
- >6 weeks suprapubic pain, frequency, urgency, worse during menstruation

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31
Q

cystitis Mx ? (3)

A
  • supportive mx: avoid alcohol/caffeine, stop smoking, pelvic floor exercises, bladder retraining, CBT
  • oral meds: analgesia, antihistamines
  • surgical: botulinum toxin injections during cystosocpoy
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32
Q

what is AKI ? what measurements ? (3)

A

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

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33
Q

what can the aetiology of AKI be divided into ?

A
  • pre-renal
  • intrinsic kidney failure
  • post-renal
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34
Q

name pre-renal causes of AKI ?

A

due to reduced renal perfusion
- low vascular volume (hypovolaemia, haemorrhage)
- low CO
- systemic vasodilation (sepsis)
- renal vasoconstriction
- overdiueresis
- HF

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35
Q

name renal causes of AKI ?

A

intrinsic kidney failure
- acute tubular necrosis
- glomerulonephritis
- interstitial nephritis

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36
Q

name post-renal causes of AKI ?

A

due to obstruction to urine
- urolithiasis

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37
Q

what is the physiology when there is reduced perfusion to the kidney ?

A

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

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38
Q

AKI RF ? (9)

A
  • age > 65
  • underlying KD
  • diabetes
  • sepsis
  • iodinated contrast
  • nephrotoxins (NSAIDs, ACEI)
  • fluid loss (excessive)
  • haemorrhage
  • drug overdose
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39
Q

overall AKI Mx ?

A
  • avoid nephrotoxic meds
  • adequate fluid intake: fluid hydration (but be careful in HF)
  • treat underling cause (stones)
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40
Q

what drugs should be avoided in AKI ?

A

stop the DAMN drugs
- Diuretics
- ACEI/ARBs
- Metformin
- NSAIDs

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41
Q

AKI complications ?

A
  • hyperkaklemiea
  • fluid overload
  • HF
  • pulmonary oedema
  • uraemia (=> encephalopathy)
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42
Q

what blood gas would be found in AKI ?

A
  • metabolic acidosis (kidney not producing as much bicarb)
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43
Q

What is CKD ?

A

abnormal structure or function for more than 3 months with implications for health

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44
Q

what values indicate CKD ?

A

abnormal function: eGFR <60ml/min or albuminaemia (urine ACR > 3mg/mmol)

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45
Q

what is creatinine ? why good to measure for kidney disease ?

A

measure creatinine (waste product of muscle metabolism - directly proportional to muscle mass), purely excreted by kidney so measure of kidney function

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46
Q

most common causes of CKD ? (3)

A
  • diabetes
  • glomerulonephritis
  • HTN/renovascular disease
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47
Q

CKD presentation ?

A

usually asymptomattic
- fatigue
- oedema
- nausea

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48
Q

what is used to stage CKD ?

A
  • GFR
  • ACR
    to stage and work out prognosis ( bad = low GFR, high ACR)
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49
Q

how is CKD diagnosed ?

A

> 3 months (documented or inferred)
- eGFR < 60ml/min
- ACR > 3 mg/mmol
(so need blood and urine test)

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50
Q

what is the general Mx of CKD ?

A

slow progression
- BP control (use ACEI/ARB)
- avoid nephrotoxins
- treat underlying disease
- anaemia
- stop smoking

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51
Q

what is renal replacement therapy ? what does it not do ?

A

RRT: removes excess water = salt + electrolytes and waste products
- but does not activate vit D or produce EPO

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52
Q

in what CKD patients should transplant be considered ?

A

G5 patients

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53
Q

what are contraindications to transplant in CKD patients ?

A
  • cancer with mets
  • active infections
  • unstable CVD
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54
Q

CKD complications ?

A
  • CKD is RF for CVD
  • all-cause mortality
  • AKI
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55
Q

how often should you monitor renal function in CKD ?

A

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

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56
Q

how does CKD affect serum phosphate and vit D levels ?

A

CKD => high serum phosphate + low hydroxylation of vit D by the kidney

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57
Q

what is glomerulonephritis ?

A

umbrella term: for inflammation + damage of the glomerulus (filters of the kidney) can be acute or chronic

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58
Q

generally what is nephrosis and nephritis ?

A

nephrotic: proteinurea due to pdocyte pathology
- nephritis: haematuria due to inflam damage

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59
Q

what is podocyte involvement in glomerulopnephritis ?

A

podocytes lay key role in glomerular filtration barrier (absence => protein in urine)

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60
Q

what does glomeruli nephritis cause ?

A
  • reduced renal efficiency
  • causes protein + RBC to leak form blood into urine
  • high BP (flame haemorrhages in eye, heart hypertrophy)
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61
Q

what is nephritis syndrome ? main symptoms ?

A

group of symptoms (not diagnosis) suggests kidney inflam
- haematuria (micro or macroscopic)
- oliguria (reduced UO)
- proteinurea
- fluid retention
- red cell cast on ruine microscopy

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62
Q

Mx of most types of glomerulonephritis ?

A
  • immunosuppression (steroids)
  • BP control by blocking RAAS (ACEI), like in CKD Mx
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63
Q

causes of nephritic syndrome ? (4) commonest cause

A
  • IgA nephropathy (most common)
  • HSP
  • post strep glomerulonephritis
  • Anti-GBM disease (good pastures)
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64
Q

what is IgA nephropathy / pathophys ? another name for it ? nephritic or nephrotic ?

A

Bergers disease - nephritic
AgI gets glycosylated (sugars stick to it) => when moves through kidney gets deposited => inflammation + scarring (nephritis)

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65
Q

what can trigger IgA nephropathy ?

A

often developed after URTI of gastroenteritis

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66
Q

how is IgA nephropathy diagnosed ?

A

kidney biopsy for diagnosis (mesangial IgA deposits + glomerular mesangial proliferation)

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67
Q

IgA nephropathy Mx ?

A
  • control BP (ACEI, ARB), RAAS inhibitors to reduce proteinurea
  • oral prednisolone if bad
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68
Q

what is post strep glomerulonephritis ? time course

A

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

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69
Q

post strep glomerulonephritis presentation ?

A

(nephritic syndrome)
- haematuria
- oedema (sign of severe of chronic disease)
- HTN
- oliguria

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70
Q

post strep glomerulonephritis diagnosis ?

A

diagnosis: renal biopsy for definitive Dx
- blood would show nephritic pic
- evidence of strep infection

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71
Q

post strep glomerulonephritis Mx ?

A

80% make full recovery
- if worsening renal function: anti-HTN (dietetic)
- main way to prevent PSGN is to prevent strep infection

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72
Q

what is anti GBM disease ? also known as ? nephritic or nephrotic ?

A

good pastures (nephritic syndrome)
- rare autoimmune
- pulmonary- renal condition characterised by anti glomerular basement membrane antibody

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73
Q

describe anti GBM disease pathosphsy ?

A

autoantibodies to alpha 3 chain in type IV collagen (found in alveoli + glomerular BM)
- causes glomerular nephritis and pulmonary haemorrhage

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74
Q

if patient present with renal failure and haemoptysis what should you consider ?

A
  • goodpastures
  • granulomatosis with polyangitis
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75
Q

anti GBM disease presentation ?

A
  • renal disease (oligo/anurea, haematuria, AKI)
  • lung disease (pulmonary haemorrhage (=> SOB, haemoptysis)
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76
Q

anti GBM disease Ix ?

A
  • anti-GBM antibody titre (=ve)
  • renal biopsy (IgG staining)
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77
Q

anti GBM disease Mx ?

A

plasma exchange
- corticosteroids (prednisolone)
- cyclophosphamide

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78
Q

what are the primary causes of nephrotic syndrome ?

A
  • minimal change disease
  • focal segmental glomerulosclerosis
  • membranous nephropathy
  • membranoproliferative GN
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79
Q

what is nephrotic syndrome ? triad ?

A

kidney disorder that causes your body to pass too much protein in urine (BM becomes highly permeable to protein)
- proteinurea
- hypoalbumaemia
- peripheral oedema

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80
Q

nephrotic syndrome presentation ?

A
  • frothy urine
  • generalised oedema
  • Pallor
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81
Q

what does nephrotic predispose to ? complications

A
  • thrombosis (due to increased clotting factors)
  • infection (due to Ig loss)
  • hypertension
  • high cholesterol
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82
Q

what would be found on investigation of nephrotic syndrome ?

A

classic triad: low serum albumin, high urine protein, oedema
- deranged lipid proflie
- high BP
- hypercoagulabilty
- haematuria usually absent

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83
Q

nephrotic syndrome mx ?

A
  • reduce oedema (fluid + salt restriction, diuretics - furo)
  • treat underlying cause (renal biopsy)
  • reduce proteinuria and BP (ACEI/ARB)
  • complications (VTE prophylaxis, avoid infection)
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84
Q

most common nephrotic syndrome in children ? adults ?

A

children: minimal change disease (idiopathic)
- adults: focal segmental glomerulosclerosis

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85
Q

what is minimal change disease ?

A

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)

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86
Q

minimal change disease aetiology ?

A
  • mostly idiopathic
  • secondary to HL, leukaemia, hep B/C infection
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87
Q

minmal change disease Ix ?

A

biopsy appears normal but fused podocytes on electron microscopy
- diagnosis usually made on clinical grounds

88
Q

minmal change disease Mx ?

A

nephrotic syndrome
- high dose steroids (prednisolone), 4 - 16 weeks
- low sal diet
- dieretic (for oedema)
- albumin infusions (if severe hypoalbuminaemia)

89
Q

what is focal segmental glomerulosclerosis ?

A

(nephrotic syndrome)
- injury to podocytes in renal glomeruli which can lead to nephrotic syndrome

90
Q

focal segmental glomerulosclerosis RF ? (4)

A
  • male
  • FSGS FHx
  • HIV
  • obesity
91
Q

focal segmental glomerulosclerosis Ix ? diagnostic ?

A
  • dx: biopsy ( glomeruli have scarring of certain segments - focal sclerosis)
  • nephrotic picture
92
Q

focal segmental glomerulosclerosis Mx ?

A
  • corticosteroids, ACEI, low salt diet
  • if secondary cause then treat underlying cause
93
Q

what is membranous nephropathy ?

A

(nephrotic syndrome)
chronic immunologically mediated glomerular BM disease that can resolve spontaneously
- can have stable real function or progress to end stage renal failure

94
Q

membranous nephropathy pathophys ?

A

thickening of glomerular capillary wall, IgG + compliment deposit in sub epithelial surface which causes leaky glomerulus

95
Q

membranous nephropathy aetiology ?

A

(nephrotic syndrome)
- primary: glomerular podocyte membrane antigen targeted (PLA2R)
- autoimmune conditions, viruses, drugs, tumours

96
Q

membranous nephropathy Ix ?

A

idiopathic diagnosis should only be made after secondary causes excluded
- serum PLA2R Ab, renal biopsy (definitive)

97
Q

membranous nephropathy Mx ?

A

low risk: control oedema, HTN, hyperlipidaemia, proteinurea
- higher risk: prednisolone

98
Q

what is the commonest case of end stage renal failure ?

A

diabetic nephropathy

99
Q

how does DM affect kidneys ?

A

hyperglycaemia => RAAS activation, oxidative stress => increase glomerular capillary pressure + podocyte + endothelial dysfunction => reduced renal function
(worsened be co-existing HTN)

100
Q

HUS triad ?

A

triad px: haemolytic anaemia, low platelets, AKI
(with haematuria/proteinurea)

101
Q

what is rhabdomyolysis ? pathophys

A

results from skeletal muscle breakdown => release of intracellular contents (K+, myoglobin) into extracellular space

102
Q

rhabdomyolysis Dx ? Ix ?

A
  • serum myoglobin
  • plasma CK > 5 times upper limit
103
Q

rhabdomyolysis Mx ? (3)

A
  • supportive
  • urgent hyperkalaemia mx
  • IV fluid rehydration
104
Q

what is polycystic kidney disease ?

A

it is a genetic condition where kidney develop multiple fluid filled cysts => significantly impaired kidney function
- also associated with haptic + cerebral aneurysms

105
Q

what are the two types of polycystic kidney disease ? who affected by both ?

A
  • adults: autosomal dominant (more common), 2/3 require renal replacement
  • babies: autosomal recessive (presenta antenatally)
    (progressive renal failure by around 50)
106
Q

polycystic kidney disease signs ? (5)

A
  • HTN
  • haematuria
  • polyuria
  • abdo/loin pain
  • palpable masses
107
Q

dominant polycystic kidney disease mx ?

A

tolvaptan (slow progression to renal failure)
- antihypertensives, analgesia
- increased daily water intake

108
Q

what are nephrolithiasis ?

A

president of crystallin stones (calculi) in urinary system (kidneys + ureter)
- usually originate in collecting duct and deposit from renal pelvis => urethra

109
Q

what are the constituents of urinary stones ?

A

urinary constituents
- calcium oxalate
- calcium phosphate
- urate

110
Q

urinary stones RF ?

A
  • chronic dehydration
  • diet (high NaCl)
  • obesity
  • meds
  • male
111
Q

urinary stones px ?

A

often asymptomatic, acute renal colic pain (severe), loin pain, UTI symptoms
- usually always UNI-lateral

112
Q

urinary stones Ix ?

A

NC-CT KUB
- urinalysis

113
Q

urinary stones Mx ? depends on what ?

A

depends on size, location, composition
- analgesia (IV NSAID, opiates)
- stone < 5mm in lower ureter: pass spontaneously, increase fluid intake
- stone: > 5mm/ medical or procedure

114
Q

urinary stones mx when stone > 5mm ??

A
  • try medical expulsion: nifedipine or tamsulosin
  • if fails: try extracorporeal shock wave lithotripsy (ESWL)
  • if obstruction of infected: ureteric Sten
115
Q

urinary stone complication ?

A

always remember sepsis
- infected obstructed kidneys can kill, need to drain so methods of drainage: ureteric stent, nephrostomy

116
Q

what is obstructive uropathy ? lead to what ?

A

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)

117
Q

what is vesicoretertic reflux ?

A

VUR is urine refluxing from bladder back into ureters

118
Q

obstructive uropathy px ?

A
  • 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
119
Q

common causes of obstructive uropathy ? upper ? lower ?

A
  • upper: kidney stones, tumours, ureter strictures (scar tissue), retroperitoneal fibrosis, bladder cancer
  • lower: BPH, prostate/bladder cancer, urethral structures
120
Q

obstructive uropathy Dx ?

A

ultrasound

121
Q

obstructive uropathy mx ?

A

remove or bypass the obstruction
- nephrostomy to bypass obsturciotn of upper UT, or ureteric stent
- lower: urethral catheter

122
Q

if cause of obstructive uropathy is prostatic obsturciotn, what is the mx ?

A

star alpha blocker (tamulosin)

123
Q

obstructed infected kidney Mx ?

A

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)

124
Q

what is benign prostatic hyperplasia (BPH) ? which area of prostate ?

A

increase in epithelial + stroll cell numbers in periurethral area of prostate 9due to increase in cell number of reduced apoptosis or both)

125
Q

what is the static and dynamic component of BPH ?

A
  • static component: increase benign prostatic tissue => narrowing of urethral lumen => LUTS
  • dynamic component: increase prostatic smooth muscle (alpha adrenergic mediated) => LUTS
126
Q

link between androgens and BPH ?

A

androgens do not cause BPE but required (androgen withdrawal => partial involution)

127
Q

BPH Px ?

A

LUTS: hesitancy, weak flow, urgency, frequency, intermittency, straining, terminal dribbling, incomplete emptying (=> chronic retention), nocturia, haematuria

128
Q

what scoring system can be used to assess severity of LUTS ?

A

international prostate symptoms score (IPSS)

129
Q

what is done on assessment for BPH ?

A
  • DRE (assess size, shape, characteristics of prostate)
  • abdo exam
  • urinary frequency volume chart
  • urine dipstick
  • prostate specific antigen
130
Q

what conditions can cause a raised PSA ?

A
  • prostate cancer
  • BPH
  • prostatic
  • UTI
  • recent ejaculation
  • cycling
131
Q

BPH mild symptoms Mx ?

A

no interventions

132
Q

BPH medical option ? how do they work ?

A
  • alpha blockers (tamsulosin): relax smooth muscle (quick response)
  • 5-alpha redacts inhibits (finasteride): dihydrotestostone: reduce size of glandular prostate)
133
Q

what is something that the patient needs to know about finasteride ?

A

excreted in semen so need to use condoms

134
Q

BPH surgical options ?

A

transurethral resection of the prostate (TURP): remove part of the prostate from inside the urethra

135
Q

TURP side effects ?

A
  • bleeding
  • infection
  • urinary incontinence
  • ED
  • retrograde ejaculation
136
Q

when to refer for 2WW for prostate cancer ?

A

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

137
Q

most common aetiology of prostate cancer ?

A

most are: adenocarcinoma that occurs in peripheral part of prostate => spreads locally through prostate capsule (seminal vesicles, peri-prostatic tissue, bladder neck)

138
Q

prostate cancer RF ?

A
  • male
  • > 50
  • black ethnicity
  • FHx
139
Q

explain about the link between PSA and prostate cancer ?

A

can be elevated for many reasons
- 70% of men with raised PSA DONT have cancer
- 6% with cancer have normal PSA (not 100% sensitive)

140
Q

what would be seen on DRE in prostate cancer ?

A

may show hard, irregular, modular, craggy prostate)

141
Q

prostate cancer Dx ?

A

TRUS- guided, or MRI-TRUS fusion-guided (needed to confirm diagnosis)

142
Q

what grading is used for prostate cancer ? describe a bit ?

A

Gleason grading (guides mx)
1 (normal) - 5 (high grade)
- high grade more likely to metastasis and spread

143
Q

when do treatment for prostate cancer ?

A
  • if < 70 + symptomatic: surgery (radical prostatectomy)
  • if > 70 + mild symptoms: consider hormone therapy or active surveillance
144
Q

what is the commonest cancer in men 20 - 45 ? prognosis ?

A

testicular cancer
- highly curable (early diagnosis)

145
Q

testicular cancer presentation ?

A

hard, painless nodule on one testis (noticed by patient or on screening)
- non trans illuminable
- gynaecomastia

146
Q

most common aetiology of testicular cancer ?

A

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

147
Q

what usually causes metastasis in testicular cancer ?

A

metastases usually caused by lymphatic spread (spermatic cord => lymph node - retroperitoneal)

148
Q

testicular cancer RF ?

A
  • undescended testes
  • gonadel dysgenesis
  • FHx of testicular cancer
  • HIV infection
149
Q

testicular cancer Ix ? what on the day ?

A
  • scrotal USS to be done that day
  • tumour markers
  • CXR (to look for metastases to work out staging)
  • CT (enlarged retroperitoneal lymph nodes
150
Q

what tumour markers useful in testicular cancer ?

A

alpha fetoprotein and bHCG are useful tumour markers + help monitor treatment

151
Q

testicular cancer Mx ?

A

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)

152
Q

radical orchiectomy complications ?

A

infertility (also risk associate with chemo - done in mx of testicular cancer)

153
Q

renal cell carcinoma - what is it ? most common aetiology ?

A

renal cell carcinoma (adenocarcinoma)
- common, found incidentally half the time (accounts of 90% real cx)

154
Q

where does most renal cell carcinoma arise ?

A

proximal renal tubular epithelium

155
Q

renal cell carcinoma symptoms ? classic triad ?

A

60 - 70 yo
- 50% found incidentally
- *haematuria
- *loin pain
- *abdominal mass
- anorexia

  • <10% present with classic triad, most found incidentally on imaging
156
Q

renal cell carcinoma RF ? (5)

A
  • 15% of haemodialysis patients develop RCC
  • smoking
  • HTN
  • obesity
  • age
157
Q

renal cell carcinoma Ix ?

A
  • imaging: US, CT/MRI
158
Q

renal cell carcinoma mx ?

A
  • radical nephrectomy
  • RCC is generally radio + chemo resistant
159
Q

bladder cancer - most common etiological subtypes ?

A

cancer in the bladder arises from endothelial lignin (urothelium)
- transitional cell carcinoma (90%)
- SCC (5%)
- adenocarcinoma

160
Q

bladder cancer px ?

A
  • painless haematruia
  • recurrent UTIs
  • voiding irritability
161
Q

bladder cancer Ix ? dx ?

A
  • flexible or rigid cystoscopy + biopsy (diagnostic)
  • CT urogram (dx and provides staging)
162
Q

bladder cancer Mx ?

A
  • transurethral resection of bladder rumour (TURBIT) (non-muscle invasive)
  • incravesical chemo (after TURBIT to reduced risk of recurrence)
  • radiotherapy
163
Q

what is neuropathic ladder ?

A

dysfunction due to damage to innervation

164
Q

what is urinary incontinence ? how is it classified ? (4)

A

involuntary loss of urine F:M (2:1)
- classified: urgency, stress, mixed, overflow, continuous

165
Q

causes of incontinence in men ? (2)

A
  • prostate enlargement
  • TURP
166
Q

what is stress incontinence ?

A

involuntary loss of urine during activities that increase intra abdominal pressure ( crying, laughing) + incompetent sphincter

167
Q

stress incontence Mx ? different approaches ?

A
  • conservative: lifestyle (no alcohol, caffeine, weight loss, stop smoking), pelvic floor exercises
  • Ring pessary may help uterine prolapse
  • medical options: dulextine
168
Q

describe the pelvic floor exercises for stress incontinence ?

A

8 contractions x 3/day for 3 months

169
Q

what is urge incontinence ?

A

involuntary loss of urine proceed by urgency - idiopathic
(detrusor overactivity)

170
Q

urge incontinence mx ? what medications ? (2)

A
  • bladder training + weight loss
  • antimuscarinic (oxybutynin)
  • B-3 agonist (mirabegron) (inhibit detrusor contraction)
  • botox (injected using cystoscope)
171
Q

what can LUTS be divided into ?

A

storage symptoms
voiding symptoms

172
Q

name some storage LUTS ? (5)

A
  • frequency
  • nocturia
  • urgency
  • urgency incontinence
  • bedwetting (due to high pressure chronic retention)
173
Q

name some voiding LUTS ? (6)

A
  • hesitancy
  • straining
  • poor/intermittant stream
  • incomplete empyting
  • dribbling
  • haematuria
174
Q

common cause of voiding LUTS ? (4)

A
  • BPE
  • prostate cancer
  • urethral stricture
  • phimosis
175
Q

common causes of storage LUTS ? (4)

A
  • overactive bladder
  • cystitis
  • bladder tumour
  • bladder calculi
176
Q

what does circumcision reduce the risk of ? (2)

A

reduce risk of STIs and penile cancer

177
Q

what is balantitis ? associated with what ?

A

acute inflammation of foreskin + glans, associated with strep + staph infection

178
Q

balantitis RF ?

A
  • diabetes
  • young children with tight foreskins
179
Q

balantitis mx ?

A
  • abx
  • circumcisoin
  • hygiene advice
180
Q

what is balantitis xerotican obliterates ? mx ?

A

(BXO - equivalent of niche sclerosis in women) => phimosis
- Mx: typical steroids, circumcision may be required

181
Q

what is phimosis ?

A

foreskin occludes the meatus => balantitis + ballooning

182
Q

phimosis px ?

A

in adulthood: painful intercourse, infection, ulceration

183
Q

what is paraphimosis ? what does it lead to ?

A

irreplaceable retracted foreskin => prevent venous return => oedema + ischaemia of the glans

184
Q

paraphimosis px ?

A
  • retracted foreskin
  • penile oedema
  • possible discolouration (sign of ischaemia)
    (common in catheterised)
185
Q

paraphimosis Mx ? (3)

A
  • 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
186
Q

what is priapsim ? for how long ?

A

persistence unwanted erection > 4hrs in absence of sexual stimulation (ED)

187
Q

what are the 3 types of priapism ? describe each a bit

A
  • 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)
188
Q

low flow priapsim mx ? (2)

A
  • aspirate penis
  • alpha 1 adrenergic agonist (phenylephrine)
189
Q

describe the physiology of an erection ? what innervation

A
  • parasympathetic innervation (S2 - 4)
  • arterial dilation, smooth muscle relaxation (by NO release) , corporeal vent occlusive mechanism
190
Q

erectile dysfunction RF ?

A
  • little exercise
  • obesity
  • smoking
  • hypercholesterolaemia
  • diabetes
  • high alcohol intake
191
Q

erectile dysfunction mx ?

A
  • lifestyle modifications
  • phosphodiesterase inhibitors
192
Q

patient presents with a testicular lump - what is it ?

A

cancer until proven otherwise

193
Q

patient present with acute, tender enlargement of testes. what is it ?

A

testicular torsion

194
Q

what is epididymo-orchitis ? important Ddx ?

A
  • inflammation of epididymis and orchitis is inflammation of testicle
  • usually the result of infection

don’t forget torsion !

195
Q

causes of epididymo-orchitis ?

A

infection depend on RF (sexually active)
- E.Coli (associated with UTI)
- if < 35: chlamydia, gonorrhoea

196
Q

epididymo-orchitis px ?

A

gradual onset of minutes - hours with unilateral testicular pain
- dragging sensation in testicle
- swelling
- tenderness on palpation
- urethral discharge
- systemic symptoms

197
Q

epididymo-orchitis ix ?

A

investigated for aetiology (enteric or STI)
- urine microscopy
- culture + sensitivity
- charcoal swabs

198
Q

epididymo-orchitis mx ? (5)

A

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

199
Q

epididymo-orchitis complications ? (4)

A
  • chronic pain
  • chronic epididymitis
  • testicular atrophy
  • scrotal abscess
200
Q

what is testicular torsion ? describe he anatomy ? why emergency ?

A

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

201
Q

typical testicular torsion px ?

A

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

202
Q

testicular torsion o/e ?

A
  • firm swollen testicle
  • elevated or retracted testicle
  • absence of cremesteric reflex
  • rotation
  • high riding/transverse lie
203
Q

testicular torsion mx ?

A
  • 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)
204
Q

what testicular pathologies with transilluminate with pen torch ?

A
  • hydrocele
  • spermatocele
205
Q

what is hydrocele ?

A

collection of fluid within the tunica vaginalis
- tunica vaginalis is a sealed pouch of membrane that surround testes

206
Q

hydrocele px ? (3)

A
  • usually painless
  • present with soft scrotal swelling
  • transillumination
207
Q

hydrocele o/e ?

A

-testicule palpable within hydrocele
- soft
- fluctuant
- large

208
Q

hydrocele dx ?

A

clinical dx
- consider US

209
Q

hydrocele mx ?

A
  • if small: not much (just observe)
  • if large or symptomatic: surgery, aspiration, sclerotherapy
210
Q

what is varicocele ?

A

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

211
Q

which side more commonly affected in varicocele ? why ? what could it indicate ?

A

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)

212
Q

varicocele px ?

A

throbbing/dull pain or discomfort
- worse on standing
- dragging
- bag of worms texture (more prominent on standing)

213
Q

varicocele Ix ?

A
  • US
  • clinical Dx
214
Q

varicocele Mx ?

A

ig pain, atrophy of infertility: surgery or endovascular embolisation

215
Q

epididymal cyst px ?

A

usually asymptomattic
- may have a lump (fluctuant swellings)

216
Q

epididymal cyst Ix ? o/e ?

A
  • soft, round, separate from testicle, difficult to transilluminate
  • dx may be confirmed with US

4 - Med (16 decks)

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