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? what age do you not ?

A
  • if >65 then do not treat
  • treat in pregnancy
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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
acute prostatic presentation ? (4)
- acute LUTS onset (dysuria, frequency, perineal discomfort) - systemic signs (fever, chills, malaise) - extreme lower abdo/ejaculatory/rectal pain - tender prostate
26
acute prostatitis Ix ?
- urinalysis (leukocytes, bacteria) - urine culture (bacteria) - culture of prostatic secretions (bacteria +ve) - blood cultures (identify organism)
27
acute prostatitis Mx ?
treat with Abx (prolonged course often required if chronic prostatitis follows) - analgesia (NSAIDs)
28
acute prostatitis complications ? (3)
- develop to chronic prostatis - sepsis - urinary retention
29
what is cystitis ?
it is a chronic condition causing inflam in the bladder => LUTS + suprapubic pain
30
cystitis Presentaiton ?
similar to LUTI but more persistent (sig impact on QOL + mental health) - >6 weeks suprapubic pain, frequency, urgency, worse during menstruation
31
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
32
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
33
what can the aetiology of AKI be divided into ?
- pre-renal - intrinsic kidney failure - post-renal
34
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
35
name renal causes of AKI ?
intrinsic kidney failure - acute tubular necrosis - glomerulonephritis - interstitial nephritis
36
name post-renal causes of AKI ?
due to obstruction to urine - urolithiasis
37
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
38
AKI RF ? (9)
- age > 65 - underlying KD - diabetes - sepsis - iodinated contrast - nephrotoxins (NSAIDs, ACEI) - fluid loss (excessive) - haemorrhage - drug overdose
39
overall AKI Mx ?
- avoid nephrotoxic meds - adequate fluid intake: fluid hydration (but be careful in HF) - treat underling cause (stones)
40
what drugs should be avoided in AKI ?
stop the DAMN drugs - Diuretics - ACEI/ARBs - Metformin - NSAIDs
41
AKI complications ?
- hyperkaklemiea - fluid overload - HF - pulmonary oedema - uraemia (=> encephalopathy)
42
what blood gas would be found in AKI ?
- metabolic acidosis (kidney not producing as much bicarb)
43
What is CKD ?
abnormal structure or function for more than 3 months with implications for health
44
what values indicate CKD ?
abnormal function: eGFR <60ml/min or albuminaemia (urine ACR > 3mg/mmol)
45
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
46
most common causes of CKD ? (3)
- diabetes - glomerulonephritis - HTN/renovascular disease
47
CKD presentation ?
usually asymptomattic - fatigue - oedema - nausea
48
what is used to stage CKD ?
- GFR - ACR to stage and work out prognosis ( bad = low GFR, high ACR)
49
how is CKD diagnosed ?
> 3 months (documented or inferred) - eGFR < 60ml/min - ACR > 3 mg/mmol (so need blood and urine test)
50
what is the general Mx of CKD ?
slow progression - BP control (use ACEI/ARB) - avoid nephrotoxins - treat underlying disease - anaemia - stop smoking
51
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
52
in what CKD patients should transplant be considered ?
G5 patients
53
what are contraindications to transplant in CKD patients ?
- cancer with mets - active infections - unstable CVD
54
CKD complications ?
- CKD is RF for CVD - all-cause mortality - AKI
55
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
56
how does CKD affect serum phosphate and vit D levels ?
CKD => high serum phosphate + low hydroxylation of vit D by the kidney
57
what is glomerulonephritis ?
umbrella term: for inflammation + damage of the glomerulus (filters of the kidney) can be acute or chronic
58
generally what is nephrosis and nephritis ?
nephrotic: proteinurea due to pdocyte pathology - nephritis: haematuria due to inflam damage
59
what is podocyte involvement in glomerulopnephritis ?
podocytes lay key role in glomerular filtration barrier (absence => protein in urine)
60
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)
61
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
62
Mx of most types of glomerulonephritis ?
- immunosuppression (steroids) - BP control by blocking RAAS (ACEI), like in CKD Mx
63
causes of nephritic syndrome ? (4) commonest cause
- IgA nephropathy (most common) - HSP - post strep glomerulonephritis - Anti-GBM disease (good pastures)
64
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)
65
what can trigger IgA nephropathy ?
often developed after URTI of gastroenteritis
66
how is IgA nephropathy diagnosed ?
kidney biopsy for diagnosis (mesangial IgA deposits + glomerular mesangial proliferation)
67
IgA nephropathy Mx ?
- control BP (ACEI, ARB), RAAS inhibitors to reduce proteinurea - oral prednisolone if bad
68
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
69
post strep glomerulonephritis presentation ?
(nephritic syndrome) - haematuria - oedema (sign of severe of chronic disease) - HTN - oliguria
70
post strep glomerulonephritis diagnosis ?
diagnosis: renal biopsy for definitive Dx - blood would show nephritic pic - evidence of strep infection
71
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
72
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
73
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
74
if patient present with renal failure and haemoptysis what should you consider ? (2)
- goodpastures (anti-GBM) - granulomatosis with polyangitis
75
anti GBM disease presentation ?
- renal disease (oligo/anurea, haematuria, AKI) - lung disease (pulmonary haemorrhage (=> SOB, haemoptysis)
76
anti GBM disease Ix ?
- anti-GBM antibody titre (=ve) - renal biopsy (IgG staining)
77
anti GBM disease Mx ?
plasma exchange - corticosteroids (prednisolone) - cyclophosphamide
78
what are the primary causes of nephrotic syndrome ? (4)
- minimal change disease - focal segmental glomerulosclerosis - membranous nephropathy - membranoproliferative GN
79
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
80
nephrotic syndrome presentation ?
- frothy urine - generalised oedema - Pallor
81
what does nephrotic predispose to ? complications
- thrombosis (due to increased clotting factors) - infection (due to Ig loss) - hypertension - high cholesterol
82
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
83
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)
84
most common nephrotic syndrome in children ? adults ?
children: minimal change disease (idiopathic) - adults: focal segmental glomerulosclerosis
85
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)
86
minimal change disease aetiology ?
- mostly idiopathic - secondary to HL, leukaemia, hep B/C infection
87
minmal change disease Ix ?
biopsy appears normal but fused podocytes on electron microscopy - diagnosis usually made on clinical grounds
88
minmal change disease Mx ?
nephrotic syndrome - high dose steroids (prednisolone), 4 - 16 weeks - low sal diet - dieretic (for oedema) - albumin infusions (if severe hypoalbuminaemia)
89
what is focal segmental glomerulosclerosis ?
(nephrotic syndrome) - injury to podocytes in renal glomeruli which can lead to nephrotic syndrome
90
focal segmental glomerulosclerosis RF ? (4)
- male - FSGS FHx - HIV - obesity
91
focal segmental glomerulosclerosis Ix ? diagnostic ?
- dx: biopsy ( glomeruli have scarring of certain segments - focal sclerosis) - nephrotic picture
92
focal segmental glomerulosclerosis Mx ?
- corticosteroids, ACEI, low salt diet - if secondary cause then treat underlying cause
93
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
94
membranous nephropathy pathophys ?
thickening of glomerular capillary wall, IgG + compliment deposit in sub epithelial surface which causes leaky glomerulus (link with malignancy) Membranous Malignancy
95
membranous nephropathy aetiology ?
(nephrotic syndrome) - Malignancy (M-M, membranous malignancy) - autoimmune conditions, viruses, drugs, tumours
96
membranous nephropathy Ix ?
idiopathic diagnosis should only be made after secondary causes excluded - serum PLA2R Ab, renal biopsy (definitive)
97
membranous nephropathy Mx ?
low risk: control oedema, HTN, hyperlipidaemia, proteinurea - higher risk: prednisolone
98
what is the commonest case of end stage renal failure ?
diabetic nephropathy
99
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)
100
HUS triad ?
triad px: haemolytic anaemia, low platelets, AKI (with haematuria/proteinurea)
101
what is rhabdomyolysis ? pathophys
results from skeletal muscle breakdown => release of intracellular contents (K+, myoglobin) into extracellular space
102
rhabdomyolysis Dx ? Ix ?
- serum myoglobin - plasma CK > 5 times upper limit
103
rhabdomyolysis Mx ? (3)
- supportive - urgent hyperkalaemia mx - IV fluid rehydration
104
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
105
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)
106
polycystic kidney disease signs ? (5)
- HTN - haematuria - polyuria - abdo/loin pain - palpable masses
107
dominant polycystic kidney disease mx ?
tolvaptan (slow progression to renal failure) - antihypertensives, analgesia - increased daily water intake
108
what are nephrolithiasis ?
president of crystallin stones (calculi) in urinary system (kidneys + ureter) - usually originate in collecting duct and deposit from renal pelvis => urethra
109
what are the constituents of urinary stones ?
urinary constituents - calcium oxalate - calcium phosphate - urate
110
urinary stones RF ?
- chronic dehydration - diet (high NaCl) - obesity - meds - male
111
urinary stones px ?
often asymptomatic, acute renal colic pain (severe), loin pain, UTI symptoms - usually always UNI-lateral
112
urinary stones Ix ?
NC-CT KUB - urinalysis
113
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
114
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
115
urinary stone complication ?
always remember sepsis - infected obstructed kidneys can kill, need to drain so methods of drainage: ureteric stent, nephrostomy
116
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)
117
what is vesicoretertic reflux ?
VUR is urine refluxing from bladder back into ureters
118
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
119
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
120
obstructive uropathy Dx ?
ultrasound
121
obstructive uropathy mx ?
remove or bypass the obstruction - nephrostomy to bypass obsturciotn of upper UT, or ureteric stent - lower: urethral catheter
122
if cause of obstructive uropathy is prostatic obsturciotn, what is the mx ?
star alpha blocker (tamulosin)
123
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)
124
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
125
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
126
link between androgens and BPH ?
androgens do not cause BPE but required (androgen withdrawal => partial involution)
127
BPH Px ?
LUTS: hesitancy, weak flow, urgency, frequency, intermittency, straining, terminal dribbling, incomplete emptying (=> chronic retention), nocturia, haematuria
128
what scoring system can be used to assess severity of LUTS ?
international prostate symptoms score (IPSS)
129
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
130
what conditions can cause a raised PSA ?
- prostate cancer - BPH - prostatic - UTI - recent ejaculation - cycling
131
BPH mild symptoms Mx ?
no interventions
132
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)
133
what is something that the patient needs to know about finasteride ?
excreted in semen so need to use condoms
134
BPH surgical options ?
transurethral resection of the prostate (TURP): remove part of the prostate from inside the urethra
135
TURP side effects ?
- bleeding - infection - urinary incontinence - ED - retrograde ejaculation
136
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
137
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)
138
prostate cancer RF ?
- male - >50 - black ethnicity - FHx
139
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)
140
what would be seen on DRE in prostate cancer ?
may show hard, irregular, modular, craggy prostate)
141
prostate cancer Dx ?
TRUS- guided, or MRI-TRUS fusion-guided (needed to confirm diagnosis)
142
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
143
when do treatment for prostate cancer ?
- if < 70 + symptomatic: surgery (radical prostatectomy) - if > 70 + mild symptoms: consider hormone therapy or active surveillance
144
what is the commonest cancer in men 20 - 45 ? prognosis ?
testicular cancer - highly curable (early diagnosis)
145
testicular cancer presentation ?
hard, painless nodule on one testis (noticed by patient or on screening) - non trans illuminable - gynaecomastia
146
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
147
what usually causes metastasis in testicular cancer ?
metastases usually caused by lymphatic spread (spermatic cord => lymph node - retroperitoneal)
148
testicular cancer RF ?
- undescended testes - gonadel dysgenesis - FHx of testicular cancer - HIV infection
149
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
150
what tumour markers useful in testicular cancer ?
alpha fetoprotein and bHCG are useful tumour markers + help monitor treatment
151
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)
152
radical orchiectomy complications ?
infertility (also risk associate with chemo - done in mx of testicular cancer)
153
renal cell carcinoma - what is it ? most common aetiology ?
renal cell carcinoma (adenocarcinoma) - common, found incidentally half the time (accounts of 90% real cx)
154
where does most renal cell carcinoma arise ?
proximal renal tubular epithelium
155
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
156
renal cell carcinoma RF ? (5)
- 15% of haemodialysis patients develop RCC - smoking - HTN - obesity - age
157
renal cell carcinoma Ix ?
- imaging: US, CT/MRI
158
renal cell carcinoma mx ?
- radical nephrectomy - RCC is generally radio + chemo resistant
159
bladder cancer - most common etiological subtypes ?
cancer in the bladder arises from endothelial lignin (urothelium) - transitional cell carcinoma (90%) - SCC (5%) - adenocarcinoma
160
bladder cancer px ?
- painless haematruia - recurrent UTIs - voiding irritability
161
bladder cancer Ix ? dx ?
- flexible or rigid cystoscopy + biopsy (diagnostic) - CT urogram (dx and provides staging)
162
bladder cancer Mx ?
- transurethral resection of bladder rumour (TURBIT) (non-muscle invasive) - incravesical chemo (after TURBIT to reduced risk of recurrence) - radiotherapy
163
what is neuropathic ladder ?
dysfunction due to damage to innervation
164
what is urinary incontinence ? how is it classified ? (4)
involuntary loss of urine F:M (2:1) - classified: urgency, stress, mixed, overflow, continuous
165
causes of incontinence in men ? (2)
- prostate enlargement - TURP
166
what is stress incontinence ?
involuntary loss of urine during activities that increase intra abdominal pressure ( crying, laughing) + incompetent sphincter
167
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
168
describe the pelvic floor exercises for stress incontinence ?
8 contractions x 3/day for 3 months
169
what is urge incontinence ?
involuntary loss of urine proceed by urgency - idiopathic (detrusor overactivity)
170
urge incontinence mx ? what medications ? (2)
- bladder training + weight loss - antimuscarinic (oxybutynin) - B-3 agonist (mirabegron) (inhibit detrusor contraction) - botox (injected using cystoscope)
171
what can LUTS be divided into ?
storage symptoms voiding symptoms
172
name some storage LUTS ? (5)
- frequency - nocturia - urgency - urgency incontinence - bedwetting (due to high pressure chronic retention)
173
name some voiding LUTS ? (6)
- hesitancy - straining - poor/intermittant stream - incomplete empyting - dribbling - haematuria
174
common cause of voiding LUTS ? (4)
- BPE - prostate cancer - urethral stricture - phimosis
175
common causes of storage LUTS ? (4)
- overactive bladder - cystitis - bladder tumour - bladder calculi
176
what does circumcision reduce the risk of ? (2)
reduce risk of STIs and penile cancer
177
what is balantitis ? associated with what ?
acute inflammation of foreskin + glans, associated with strep + staph infection
178
balantitis RF ?
- diabetes - young children with tight foreskins
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balantitis mx ?
- abx - circumcisoin - hygiene advice
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what is balantitis xerotican obliterates ? mx ?
(BXO - equivalent of niche sclerosis in women) => phimosis - Mx: typical steroids, circumcision may be required
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what is phimosis ?
foreskin occludes the meatus => balantitis + ballooning
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phimosis px ?
in adulthood: painful intercourse, infection, ulceration
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what is paraphimosis ? what does it lead to ?
irreplaceable retracted foreskin => prevent venous return => oedema + ischaemia of the glans
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paraphimosis px ?
- retracted foreskin - penile oedema - possible discolouration (sign of ischaemia) (common in catheterised)
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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
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what is priapsim ? for how long ?
persistence unwanted erection > 4hrs in absence of sexual stimulation (ED)
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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)
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low flow priapsim mx ? (2)
- aspirate penis - alpha 1 adrenergic agonist (phenylephrine)
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describe the physiology of an erection ? what innervation
- parasympathetic innervation (S2 - 4) - arterial dilation, smooth muscle relaxation (by NO release) , corporeal vent occlusive mechanism
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erectile dysfunction RF ?
- little exercise - obesity - smoking - hypercholesterolaemia - diabetes - high alcohol intake
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erectile dysfunction mx ?
- lifestyle modifications - phosphodiesterase inhibitors
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patient presents with a testicular lump - what is it ?
cancer until proven otherwise
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patient present with acute, tender enlargement of testes. what is it ?
testicular torsion
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what is epididymo-orchitis ? important Ddx ?
- inflammation of epididymis and orchitis is inflammation of testicle - usually the result of infection don't forget torsion !
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causes of epididymo-orchitis ?
infection depend on RF (sexually active) - E.Coli (associated with UTI) - if < 35: chlamydia, gonorrhoea
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epididymo-orchitis px ?
gradual onset of minutes - hours with unilateral testicular pain - dragging sensation in testicle - swelling - tenderness on palpation - urethral discharge - systemic symptoms
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epididymo-orchitis ix ?
investigated for aetiology (enteric or STI) - urine microscopy - culture + sensitivity - charcoal swabs
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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
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epididymo-orchitis complications ? (4)
- chronic pain - chronic epididymitis - testicular atrophy - scrotal abscess
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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
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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
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testicular torsion o/e ?
- firm swollen testicle - elevated or retracted testicle - absence of cremesteric reflex - rotation - high riding/transverse lie
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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)
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what testicular pathologies with transilluminate with pen torch ?
- hydrocele - spermatocele
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what is hydrocele ?
collection of fluid within the tunica vaginalis - tunica vaginalis is a sealed pouch of membrane that surround testes
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hydrocele px ? (3)
- usually painless - present with soft scrotal swelling - transillumination
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hydrocele o/e ?
-testicule palpable within hydrocele - soft - fluctuant - large
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hydrocele dx ?
clinical dx - consider US
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hydrocele mx ?
- if small: not much (just observe) - if large or symptomatic: surgery, aspiration, sclerotherapy
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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
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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)
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varicocele px ?
throbbing/dull pain or discomfort - worse on standing - dragging - bag of worms texture (more prominent on standing)
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varicocele Ix ?
- US - clinical Dx
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varicocele Mx ?
ig pain, atrophy of infertility: surgery or endovascular embolisation
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epididymal cyst px ?
usually asymptomattic - may have a lump (fluctuant swellings)
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epididymal cyst Ix ? o/e ?
- soft, round, separate from testicle, difficult to transilluminate - dx may be confirmed with US