Renal/Uro Flashcards
what is interstitial cystitis?
chronic inflammation of the urinary bladder- aka bladder pain syndrome or hypersensitive bladder syndrome
what are the top 3 causative organisms for cystitis?
E.Coli - most common
Staph saprophyticus
Klebsiella pneumoniae
what is the presentation of interstitial cystitis?
> 6 weeks of
Suprapubic pain
frequency of urination
urgency of urination
symptoms may be worse during menstruation
what are 2 things that may be seen on cystoscopy in interstitial cystitis?
Hunner lesions - red inflamed patches of bladder mucosa
Granulations - tiny haemorrhages in bladder wall
what is the management of interstitial cystitis?
supportive management - diet, smoking, bladder retraining, CBT
Analgesia, antihistamines, anticholinergics
Intravesical medications (direct to bladder) - lidocaine, etc
Hydrodistension and surgery
What are 6 voiding LUTS?
weak stream
splitting or spraying, intermittency
hesitancy
straining
Terminal dribbling
incomplete emptying
What are 6 storage LUTS?
Frequency
Urgency
Nocturia
Urge incontinence
stress incontinence
leaking
what is the pathophysiology of BPH?
there is hyperplasia in the glandular epithelial and stromal cells of the prostate due to increased action of 5-alpha reductase
what are 5 risk factors for BPH?
Increasing age - 50+
FHx
Obesity
Afro-Caribbean
Diabetes
what are 3 manifestations of BPH?
Voiding LUTS
Storage LUTs
Urinary retention - lower abdo pain, inability to urinate
what are 4 initial investigation for BPH?
Urinalysis
PSA
U+E - may cause renal failure in obstruction
DRE
what is the conservative management of BPH?
treat constipation
reduce caffeine and fluid intake
medication review
retrain bladder
what is the pharmacological managements of BPH?
1 - alpha blocker
Tamsulosin 400 micrograms MR OD
2 - 5-alpha reductase inhibitor - can take up to 6 months to work
Finasteride 5mg OD PO
Phosphodiesterase-5 inhibitors can be used for severe LUTs
what are 6 indications for surgical management of BPH?
RUSHES
Recurrent refractory retention
UTIs, Recurrent
Stones in bladder
Haematuria, refractory
Elevated creatinine due to bladder outflow obstruction
Symptoms despite max medical therapy
What are 3 surgical managements of BPH?
Transurethral incision of prostate <30g
Transurethral resection of prostate 30-80g
Open prostatectomy >80g
what are 5 complications of BPH?
urinary retention
UTIs
bladder stones
renal dysfunction
haematuria
what are 3 complications of BPH surgery?`
retrograde ejaculation
erectile dysfunction
TURP syndrome - life threatening triad of fluid overload, dilutional hyponatraemia and neurotoxicity
What hormone does the prostate secrete?
Dihydrotestosterone
What is Chronic Kidney Disease?
Progressive deterioration in renal function, present for ≥3 months, with implications for health
what is the GFR value for CKD?
<60 ml/min/1.73 m2
At least 2 readings separated by at least 90 days
what is stage 1 CKD?
eGFR >90 PLUS evidence of renal damage
what is stage 2 CKD?
eGFR 60-89 PLUS evidence of renal damage
what is stage 3A CKD?
eGFR 45-59 ml/min/1.73m2
what is stage 3B CKD?
eGFR 30-44 ml/min/1.73m2
what is stage 4 CKD?
eGFR 15-29 ml/min/1.73m2
what is stage 5 CKD?
eGFR <15 ml/min/1.73m2
what are 6 finding that can evidence renal damage?
Albuminuria ACR >3mg/mmol
Urine sediment abnormalities
Electrolyte and other abnormalities due to renal disfunction
Histological abnormalities
Structural abnormalities on imaging
Hx of kidney transplant
what are 6 causes of CKD?
Diabetes - 1/3rd of people with DM
HTN
Polycystic kidney disease
Medications - NSAIDs, Lithium
Chronic Glomerulonephritis or pyelonephritis
What are 5 early manifestations of CKD?
asymptomatic in early stages
Fatigue - due to toxin build up and anaemia due to reduced EPO
Polyuria or nocturia
HTN
Puffiness or swelling
what are 8 later manifestations of CKD?
Decreased urine output
Fluid overload
Uraemic symptoms
Neuro symptoms - fatigue to seizures
Cardio symptoms
Anaemia symptoms
Bone and mineral disease
Metabolic acidosis
What are 6 symptoms of uraemia?
nausea and vom
anorexia
metalic taste in mouth
hiccups
pruritus
what are 3 investigations for CKD?
eGFR
Albumin creatinine ratio - urine spot sample - >3mg/mmol = proteinuria
FBC
what is the difference between CKD and AKI on renal US?
CKD = usually small b/l kidneys
other than if due to
- autosomal dominant polycystic kidney disease
- diabetic nephropathy
- amyloidosis
- HIV associate
who in AKI should have a renal US?
if no identifiable cause or at risk of obstruction => US within 24 hours
when should you refer to renal in CKD? 3
eGFR <30
urinary ACR >70
Decrease in eGFR 25% or 15 within 1 year
5 Year risk of dialysis over 5%
Uncontrolled HTN with 4+ hypertensives
what is the name of the formula that can be used to calculate eGFR?
Modification of diet in renal disease equation
what is the management for CKD?
Lifestyle advice - smoking, exercise, nephrotoxins, low salt and potassium diet
Optimise diabetic control
optimise HTn control
Reduce/avoid nephrotoxic drugs
Treat glomerulonephritis
How is anaemia managed in CKD?
Target Hb 100-120 g/L
Optimise iron status
Erythropoiesis stimulating agents - Darbepoetin alfa,
Blood transfusions aren’t used as can sensitise immune system (allosensitization) and increase risk of future transplant rejection
what is the management of bone disease in CKD?
1 - reduced dietary phosphate intake
Vitamin D - alfacalcidol, calcitriol
Calcium intake and supplements
Phosphate binders - calcium based binders (calcium acetate) or Sevelamer
Bisphosphonates if osteoporosis
why does CKD cause bone disease?
Kidney cannot excrete enough phosphate or convert vitamin D to active form
Reduced phosphate excretion = increased calcium sequestration
Reduced active vitamin D = reduced calcium absoprtion
Reduced serum calcium = increased PTH
Increased PTH = increased osteoclastic activity to raise serum calcium = OSTEOMALACIA and OSTEOSCLEROSIS
what is one sign of CKD bone disease on x-ray?
Rugger jersey spine on spinal X-ray
Sclerosis of both ends of vertebral body (more white) and osteomalacia (less white) in the central vertebrae
what is the 1st line management of HTN in CKD with proteinuria?
ACEi
Need close potassium monitoring
How should CVD risk be managed in CKD?
ACEi - for HTN + Proteinuria or Diabetes
Furosemide if eGFR <45 as lowers serum potassium
Atorvostatin 20mg for prevention
what SGLT-2 inhibitors are used in CKD?
DAPAGLIFLOZIN
In diabetes WITH urine ACR >30 mg/mmol
Consider in Diabetes with ACR 3-30 mg/mmol or non diabetic with ACR >22.6mg/mmol
what equation can be used to estimate 5 year risk of kidney failure requiring dialysis?
Kidney failure risk equation
what are 5 complications of CKD?
anaemia - normochromic, normocytic
CKD metabolic bone disease
Cardiovascular disease
End stage kidney disease
Secondary hyperparathyroidism
what type of anaemia is seen in CKD?
Normocytic normochromic
what percentage of CO do the kidneys receive?
25%
- 1000 ml/min
What is an epididymal cyst?
smooth, extratesticular spherical cyst in head of epididymus
what do epididymal cysts look like?
Contain clear or milky (spermatocele) fluid
Transluminate
Lie above and behind the testis
testis palpable and separate from cyst
what are 3 differentials for epididymal cyst?
spermatocele
hydrocele
varicocele
what is nephrotic syndrome?
the presence of proteinuria, hypoalbuminaemia, and peripheral oedema often caused by sclerosis of the podocytes
what are the 4 different primary nephrotic syndromes?
minimal change disease
focal segmental glomerulosclerosis
membranous glomerulonephritis
Membranoproliferative glomerulonephritis
what is the triad of nephrotic syndrome?
Proteinuria >3g /24h
Hypoalbuminaemia <30g/L
Oedema
what are 6 features of nephrotic syndromes?
Proteinuria (> 3.5 g/day)
Hypoalbuminemia(< 30 g/L) which leads tooedema
Hyperlipidaemia as the liver increases synthesis of lipids in response to low albumim
Hypogammaglobulinemia: due to loss of immunoglobulin in the urine
Hypercoagulability: due to loss of antithrombin III, and protein C and S in the urine
Deranged lipid profile - high cholesterol, triglycerids and LDL
what is there not in nephrotic syndromes?
HAEMATURIA
what are 5 general manifestations of nephrotic syndromes?
hypertension
frothy urine (lipids)
facial and peripheral oedema
recurrent infections
predisposition to thrombotic events
what are 4 investigations for nephrotic syndromes?
Urinalysis:**proteinuria > haematuria, lipid casts
24-hour urine protein collection - > 3.5 g protein
Urine albumin-creatinine ratio (ACR) -raised due to proteinuria
U&Es - monitor eGFR and creatinine to assess for renal failure
what are 5 complications of nephrotic syndrome?
increase risk of thromboembolism
Hyperlipidaemia
CKD
Increased risk of infection
hypocalcaemia
what is the most common nephrotic syndrome affecting children?
minimal change disease
what is seen in the urine in minimal change?
small molecular weight proteins
hyaline casts
what might minimal change disease be preceded by?
a upper respiratory tract infection
what cancer is associated with minimal change disease?
Hodgkin’s lymphoma
what is the pathophysiology of minimal change?
T cells release cytokines-glomerular-permeability factor => flattens out podocytes (effacement) so they fuse together => allow albumin (but not immunoglobulins) into nephron => selective proteinuria
what is the management for minimal change disease?
corticosteroids - prednisolone!!!
fluid restriction and low salt diet
diuretics
immunosuppressants
what is the most common cause of nephrotic syndrome is adults?
Membranous glomerulonephritis
what are 4 potential causes of focal segmental glomerulosclerosis?
heroine use
HIV infection
sickle cell disease
SLE
what is seen on light microscopy in focal segmental glomerulosclerosis?
sclerosis and hyalinosis
only parts of some glomeruli are affected
what are 4 secondary causes of nephropathy?
SLE
Drugs - NSAIDS, gold
infection - Hep B/C, syphilis
tumours
is focal segmental glomerulosclerosis a nephrotic or Nephritic?
nephrOtic
is minimal change disease nephrotic or nephritic?
nephrOtic
what is seen histologically in membranous glomerulonephritis?
diffuse capillary and basement membrane thickening due to immune complex deposition
spike and dome pattern of basement membrane
what is the management of membranous gomerulonephritis?
ACEI
Immunosuppression
Corticosteroids are INEFFECTIVE
what is nephrolithiasis?
kidney stones
what are 6 risk factors for renal stones?
Male
Prev stones
Dehydration
Hypercalcaemia, hypercalciuria, hyperparathyroid
Renal tubular acidosis
Gout - for urate stones
what are 4 drugs that increase risk of renal stones?
Loop diuretics - furosemide
Steroids
Acetazolamide
Theophylline
what is the most common composition of renal stones?
calcium oxalate
black/dark brown stones, more likely to form in acidic urine
radiopaque
what are struvite renal stones associated with?
UTI
what can struvite renal stones cause?
Staghorn caliculi - branching calcifications due to recurrent UTIs
what type of renal stones are radiolucent?
Uric acid
Associated with gout and malignancy
what causes cysteine renal stones?
Cystinuria in autosomal recessive cystinuria disorder
what are 5 manifestations of renal stones?
Loin to groin severe renal colic
Haematuria
Nausea and vomiting
reduced urine output
Symptoms of sepsis/infection
what are 3 investigations for renal stones?
non-contrast CT kidney, ureter and bladder - GOLD
urinalysis - haematuria
U+Es - raised creatinine - AKI due to obstruction
what is the 1st line investigation for renal stones?
Urinalysis - haematuria
bloods -inflammatory markers, u+e, bone profile and urate
what is the gold standard investigation for renal stones and how quickly should it be done?
Non-contrast CT KUB
within 14 hours of admission or immediately in sepsis or one kidney
what is the initial management of renal stones?
IV fluids
anti-emetics - metoclopramide, prochlorperazine, cyclizine
NSAIDs - IM diclofenac or IV paracetamol if contraindicated
antibiotics - if infection
Alpha blockers - tamsulosin - cause smooth muscle relaxation may aid passage/ease pain
what analgesia is given in renal stones?
1 - IM diclofenac
2 - IV paracetamol if NSAIDs contraindicated
what is the management for renal stones <5mm?
watchful waiting
what is the management of renal stones 5-10mm?
Shockwave lithotripsy
what is the management of renal stones 10-20mm?
Shock wave lithotripsy or ureteroscopy
what is the management of renal stones >20mm?
percutaneous nephrolithotomy
what are 6 strategies for preventing renal stones?
Increase fluid intake
add lemon juice to drinking water
avoid carbonated drinks
limit salt intake
potassium citrate
thiazide diuretics
what are 5 complications of renal stones?
obstruction and hydronephrosis
Urethral strictures
Infection and urosepsis
CKD and AKI
Recurrence
what is testicular torsion?
a urological emergency caused by the twisting of the testicle on the spermatic cord leading to constriction of the vascular supply, time-sensitive ischaemia, and/or necrosis of testicular tissue.
what deformity makes testicular torsion more likely?
Bell clapper - testicle lies in more horizontal position and has improper attachment of tunica vaginalis
what are 5 risk factors for testicular torsion?
Young age - peak incidence 13-15 years
Trauma/exercise
undescended testicles
Bell-clapper deformity
what are 5 manifestations of testicular torsion?
severe testicular pain
elevated testicle
no relief upon scrotal elevation
scrotal swelling or oedema
abnormal testicular lie
absent cremasteric reflex
Rotation - non-posterior epididymis
Associated with nausea and vomiting
what are 4 investigations for testicular torsion?
US testicle - fluid and whirlpool sign
power doppler ultrasound - decreased blood flow
colour doppler ultrasound - decreased blood flow
surgical exploration - gold
what sign might be seen on USS of the testicles in testicular torsion?
whirlpool sign - spiral appearance of spermatic cord and blood vessels
what is the management for testicular torsion?
nil by mouth
analgesia
urgent senior urology assessment
surgical exploration of scrotum
Bilateral orchiopexy
orchidectomy if needed
what is urethritis?
inflamation of the urethra - usually a sexually transmitted disease that typically presents with dysuria, urethral discharge, and/or pruritus at the end of the urethra
what are 4 organisms that cause urethritis?
Chlamydia trachomatis - gram -ve - most common
N. gonorrhoea - gram -ve diplococci
Mycoplasma genitalium
ureaplasma urealyticum
what are 3 risk factors for urethritis?
15-24 years
multiple sexual partners/new sexual partner
unprotected sex
what are 5 manifestations of urethritis?
may be asymptomatic
acute urethral discharge following unprotected sex
irritation/itching
dysuria
orchalgia/pelvic pain
no rash or arthritis
what are 2 investigations for urethritis?
Nucleic acid amplification test
Gram stain, microscopy and culture of urethral discharge/urine sediment
what are 3 complications of uretheritis?
epididymitis
subfertility
reactive arthritis
what is the management of urethritis?
Doxycycline 100mg BD 7 days
THEN
Azithromycin 1g stat then 500mg BD for 2 days
NO DOXY IN PREGNANCY
Test of cure
what is the 1st and 2nd line treatment for chlamydia ?
1 - Doxycycline
2 - Azithromycine
what are 3 complications of urethritis?
reactive arthritis
gonococcal conjunctivitis
prostatitis
what is the most common causative organism of uncomplicated UTIs?
E. Coli
what is classed as an uncomplicated UTI?
Caused by typical uropathogens in non-pregnant women with no known anatomical or functional abnormalities of the urinary tract
what is classed as a recurrent UTI?
2+ UTIs in 6 months or 3 + in one year
what are the 5 organisms that most often cause UTIs?
KEEPS
klebsiella pneumoniae
E. coli
Enterococci
Proteus aprophyticus
Staphylococcus saprophytic - coagulase -ve
what are 9 risk factors for UTIs?
Sexual activity
Female
post-menopausal
Pregnancy - physiological urinary statsis and vesicoureteral reflux
Catheters
BPH/Prostitis
Dysfunctional voiding
Anatomical abnormalities - vesicoureteral reflux, renal stones
Immunosupression
what are 7 manifestations of UTIs?
Dysuria
Frequency
Urgency
Cloudy/offensive smelling urine
Haematuria
Lower abdo pain
Fever - low grade
malaise
acute confusion in elderly
what are 3 investigations for UTI?
urine dipstick - + nitrates and leukocytes
Urine MSU for MCS - always in complicated patients
what is the management of uncomplicated UTI?
1 - Nitrofurantoin 100mg MR BD for 3 days
OR
Trimethoprim 200mg BD for 3 days
2 - Nitrofurantoin 100mg MR BD for 3 days
OR
Pivmecillinam 400mg initially then 200mg TDS for 3 days
OR
Pivmecillinam 3g single dose sachet
when should women with haematuria be referred 2ww to urology?
> 45 with visible haematuria after successful UTI treatment
60 with unexplained non-visible haematuria and either and either dysuria or raised WCC
when should women with recurrent UTIs be referred to Uro?
> 60 years recurrent or persistent unexplained UTI
40 and no know cause
what are 5 self care measures women can take to prevent UTI?
avoid risk factors
maintain adequate hydration - 1.5L a day
Avoid douching and wearing occlusive underwear
Wipe from to back
Avoid delay or habitual or post coital urination
Do not recommend use of over the counter products of d-mannose
what antibiotics can be used as prophylaxis in recurrent uncomplicated UTI?
1 - trimethoprim 100mg at night
OR Nitrofurantoin 50-100mg
2 - amoxicillin 250mg at night
OR cefalexin 125mg at night
what is the management of UTI in pregnancy?
SEND FOR MCS
1 - Cefalexin 500mg TDS 7 days
OR
Amoxicillin 500mg TDS 7 days
OR
Nitrofurantoin 100mg MR BD 7 days
OR
Trimethoprim 200mg BD 7 days
when should nitrofurantoin be avoided in pregnancy?
3rd trimester due to risk of neonatal haemolysis
when should trimethoprim be avoided in pregnancy?
1st trimester works as a folate antagonist - congenital malformations, neural tube defects
How should asymptomatic bacteriuria in pregnancy be managed?
immediately with same ABx as UTI - due to risk of progression to pyelo
How long should complicated UTIs be treated for?
7 days
what is a contraindication to nitrofuranoin?
eGFR <45
also avoid in 3rd trimester pregnancy
what are 5 complications of UTI?
Acute/chronic pyelonephritis
Urosepsis
Renal/peri-renal abscess
AKI
Increased risk pre-term delivery in pregnancy
what is varicocele?
the abnormal dilation of the internal spermatic veins and pampiniform plexus that drain blood from the testis caused by venous reflux
which teste is varicocele most common in?
left - due to increased resistance in L testicular vein which drains into L renal vein whereas R testicular vein drains into IVC
what are 2 risk factors for varicocele?
somatic factors - tall/ low BMI
what are 6 manifestations of varicocele?
Throbbing, dull pain or discomfort worse on standing
Dragging sensation
Subfertility or infertility
O/E
- scrotal ‘bag of worms’ mass
- more prominent on standing
- disappears when lying
when should varicoceles be referred for urgent investigation?
if do not disappear on lying - may be due to retroperitoneal tumours obstructing renal vein drainable
what can be used to confirm diagnosis of varicocele?
US doppler
Semen analysis
Hormonal testing
what is one possible surgical intervention for varicocele?
Surgery or endovascular embolization
what are 3 complications of varicocele?
Infertility
Testicular atrophy
Pain
what is nephritic syndrome?
inflammation of the glomerular basement membrane within the nephron leading to haematuria and limited proteinuria
what are the 6 different types of nephritic syndromes?
post-streptococcal glomerulonephritis
IgA nephropathy
diffuse proliferative glomerulonephritis
membranoproliferative glomerulonephritis
rapidly progressing glomerulonephritis
alport syndrome
which 3 nephritic syndromes are caused by type III hypersensitivity?
post-streptococcal glomerulonephritis
IgA nephropathy
Diffuse proliferative glomerulonephritis
what are 5 manifestations of nephritic syndromes?
haematuria
proteinuria < 3.5g/day
arterial hypertension
peripheral and peri-orbital oedema
decreased urine output
what are 3 investigations for nephritic syndromes?
bloods - increased creatinine and blood urea nitrogen
urinalysis - haematuria, RBC cast, proteinuria <3.5g/day
renal biopsy
what is the management for nephritic syndromes?
immunosuppression - steroids
blood pressure control - ACEi/ARB (furosemide)
statins
omega-3 fatty acids
what are 2 complications of nephritic syndromes?
AKI
CKD
what is post-streptococcal glomerulonephritis?
nephritic syndrome occurring 7-14 days after infection with B-haemolytic strep (tonsillitis). Immune complexes of strep antigens, antibodies and complex proteins get stuck in the glomeruli
what investigation can be done for post-streptococcal glomerulonephritis?
anti-streptolysin antibody titres
what is IgA nephropathy?
an autoimmune nephritic syndrome caused by mesangial IgA immune deposits presenting with macroscopic haematuria usually 1-2 days following an URTI
usually in teenagers and young adults
what is the most common nephritis?
IgA nephropathy
what are 4 risk factors for IgA nephropathy?
male
HIV
FHx
ethnicity - asian
what usually precedes IgA nephropathy?
upper respiratory tract infection (or less usually gastroenteritis) 1-2 days before
what is the management of IgA nephropathy?
proteinuria 500-1000 - follow up
proteinuriea >1000/day - ACEI
Falling GFR, failure to respond - Immunosuppression with corticosteroids
what are 4 causes of rapidly progressive glomerulonephritis?
goodpasture’s syndrome
wergener’s granulomatosis
SLE
Polyarteritis
what is the most common form of lupus nephritis?
diffuse proliferative glomerulonephritis - also worst prognosis
what are 4 risk factors for membranoproliferative glomerulonephritis?
age 8-16
infections
CLL
acquired partial lipodystrophy
what can cause rapidly progressive glomerulonephritis?
goodpasture’s syndrome
IgA GN
Post-streptococcal GN
ANCA associated
what is a fungi that can cause cystitis in the immunosuppressed and those with indwelling catheters?
Candida
what is xanthogranulomatous pyelonephritis?
a chronic kidney infection caused by an infected kidney stone causing obstruction
what is the most common causative pathogen of prostatitis?
E. coli
what is chronic prostatitis?
prostatitis lasting >3 months
what are 4 risk factors for acute bacterial prostatitis?
recent UTI
Urogenital instrumentation
intermittent catheterisation
recent prostate biopsy
HIV
Anal sex
what are 5 presentations of prostatitis?
Pelvic pain
LUTS
Sexual dysfunction
Pain with bowel movements
Tender and enlarged protate
if acute bacterial may also have fever, myalgia, nausea, fatigue, sepsis
what scoring system can be used to assess chronic prostatitis symptoms/
national institute of health chronic prostatitis symptom index
what are 3 investigations for prostatitis?
Urine dip
Urine MCS
Chlamydia and gonorrhoea NAAT
what is the management of acute bacterial prostatitis?
14 days oral ciprofloxacin (orafloxacin, trimethoprim)
Analgesia
Laxatives
Admission if required
what are 5 management options for chronic prostatitis?
Alpha blockers - tamsulosin
analgesia
Psychological treatment
Abx
Laxatives
what are 4 complications of prostatitis?
acute urinary retention
chronic prostatitis
prostatic abscess
sepsis
what is prehn’s sign and what conditions is it positive in?
pain relief with lifting affected testicle
positive in orchitis and epididymitis
NEGATIVE IN TORSION
what 2 genes are affected in autosomal dominant polycystic kidney disease?
PKD1 and PKD2
on chromosome 16 and 4 respectively
what is the presentation of autosomal dominant polycystic kidney disease?
haematuria
loin pain
hypertension
recurrent UTIs
Kidney stones
SAH
palpable kidneys/mass
what is the criteria for diagnosis of autosomal dominant polycystic kidney disease on US?
<30 years - 2 cystic unilateral or b/l
>30 - 2 cysts in each kidney
>60 - 4 cysts in each kidney
what are 4 extrarenal manifestations of autosomal dominant polycystic kidney disease?
Cerebral aneurysm - berry
Hepatic, splenic, pancreatic, ovarian, prostatic cysts
Mitral regurgitation
Colonic diverticula
what cardiac condition is associated with autosomal dominant polycystic kidney disease?
mitral regurg
what are 6 complications of autosomal dominant polycystic kidney disease?
chronic loin/flank pain
hypertension
fross haematuria
recurrent UTIs
Renal stones
end stage renal failure around 50 years
is autosomal dominant or recessive polycystic kidney disease more common?
dominant
recessive is more severe but less common
what is the presentation of autosomal recessive polycystic kidney disease?
Usually on antenatal scans due to oligohydramnios which leads to underdeveloped foetal lungs and respiratory failure
often develop end stage renal failure before adulthood
May have dysmorphic features - underdeveloped ear cartilage, low set ears, flat nasal bridd=ge
what medication can be used to slow development of cysts in autosomal dominant polycystic kidney disease?
Tolvaptan - vasopressin receptor antagonist
where in the brain is the micturition centre?
the pons
berry aneurysms are a complication of what renal disease?
autosomal dominant polycystic kidney disease
What is the treatment for syphilis?
Benzanthine Penicillin and Azithromycin
when is trimethoprim most teratogenic?
1st trimester
when is nitrofurantoin not recommended in pregnancy?
3rd trimester
what s oxybutynin used for?
overactive bladder
is there hyperlipidaemia in nephritic syndromes?
NO!!! only nephrotic
what condition can cause muddy brown casts on urinalysis?
acute tubular necrosis
what are the 6 functions of the kidney?
Fluid volume management
Waste excretion and selective reabsorption
RBC production
Vitamin D metabolism
Acid-base regulation
Blood pressure management
what is glomerulonephritis?
any of a group of diseases that injure the part of the kidney that filters blood (the glomeruli).
what are the characteristic finding is nephrotic syndromes?
oedema
proteinuria
decreased protein and increased lipids in blood
what are the characteristic features of nephritic syndromes?
blood in the urine (especially Red blood cell casts with dysmorphic red blood cells) and a decrease in the amount of urine in the presence of hypertension
what are the criteria for the 2 week wait for bladder cancer?
45+ with unexplained visible haematuria without UTI
60+ with unexplained non-visible haematuria and either dysuria or a raised WCC
what percentage of men with raised PSA will not have prostate cancer?
specificity = 30%
what percentage of men with normal PSA will have prostate cancer?
sensitivity = 94%
what is erectile dysfunction?
the persistent inability to attain and maintain an erection to permit satisfactory sexual performance
what are 10 risk factors for erectile dysfunction?
Older age
obesity
diabetes
dyslipidaemia
metabolic syndrome
hypertension
smoking
alcohol
SSRIs
Beta blockers
what is the difference in presentation between organic and psychogenic erectile dysfunction?
organic is gradual onset inability to get hard, normal libido
psychological is sudden onset, decreased libido, good quality spontaneous/self stimulated erections, major life events/stress, prev psych problems, Hx of premature ejaculation
what are 3 organic causes of erectile dysfunction?
Vasculogenic - most common
Neurogenic - Parkinson’s, stroke, DM
Anatomical/structural
what are 2 investigations for erectile dysfunction?
QRisk calculated
Free testosterone - 9-11am
what is the 1st line treatment for erectile dysfunction?
phsophodistesterase-5 inhibiters
SILDENAFIL
what is the 1st line management of erectile dysfunction if refusing/unable to take medication?
vacuum erection devices
what are 3 physical causes of premature ejaculation?
Prostitis
hormonal problems - thyroid
Using recreational drugs
what are 4 psychological causes of premature ejaculation?
depression
stress
relationship problems
anxiety
what is the management of premature ejaculation?
Psychosexual counselling
SSRIs
Phosphodiesterase-5 inhibitors
Local anaesthetic creams, sprays or condoms
Masturbation before intercourse
what is a UTI?
bacteria in the urine combined with clinical features
when would you refer someone with UTIs for a bladder cancer review?
60+ with recurrent/persistent UTIs
what are 4 risk factors for pyelonephritis?
Female
Structural abnormalities
vesico-ureteric abnormalities
Diabetes
what are 4 bacteria that cause pyelonephritis?
E. coli - most common
Klebsiella species
proteus mirabilis
pseudomonas species
what is the triad of pyelonephritis?
loin/back pain (renal angle tenderness)
fever
Nausea/vomiting
what is the 1st line management of pyelonephritis?
Cefalexin 500mg BD - 7-10 days
if sensitive - Co-amoxiclav 500/125mg TDS - 7-10 days
if sensitive - Trimethoprim 200mg BD - 14 days
Ciprofloxacin 500mg BD - 7 days
what are 2 IV Abx for severe pyelonephritiss?
Gentamicin
Ciprofloxacin 400mg TDS
what is the 1st line pyelonephritis management in pregnancy?
Cefalexin 500mg TDS 7-10 days
what scan can be done to look for kidney scaring in chronic pyelonephritis?
Dimercaptosuccinic acid (DMSA) scan
what is the management of epididymal cysts?
Observation and scrotal support if needed
Aspiration and sclerotherapy
Surgical excision
what is a hydrocele?
collection of fluid in the tunica vaginalis that surrounds the testes
what is the presentation of hydrocele?
Swollen scrotum with testicles palpable inside hydrocele
Soft and fluctuant
Irreducible and no bowel sounds
Transilluminates
what are 5 causes of hydrocele?
idiopathic
Testicular cancer
testicular torsion
Epididymo-orchitis
trauma
what are the 2 different types of hydrocele?
Simple - just due to trapped fluid
Communicating - fluid coming from peritoneal cavity via the processus vaginalis leading to fluctuant size
what is the management of a simple hydrocele?
usually self resolves
what is the management of a communicating hydrocele?
ligation/removal of processus vaginalis
what are 4 causes of epididymo-orchitis?
Escherichia coli
Chalmydia trachomatis
Neisseria gonorrhoea
Mumps - often only orchitis
what is the presentation of epididymo-orchitis?
Gradual onset
Testicular pain
dragging or heavy sensation
swelling of testicle or epididymis
Tenderness on palpation
urethral discharge - chlamydia or gonorrhoea
Systemic symptoms
what are 6 investigations for epididymo-orchitis?
urine MSC
first pass urine NAAT for chlamydia and gonorrhoea
Charcoal swab
saliva swab for mumps
serum antibodies for mumps
US testicles
what is the management of e. coli epididymo-orchitis?
Ofloxacin 14 days
Levofloxacin 10 days
Co-amox 10 days - when quinolones contraindicated
what are 2 side effects of quinolones?
Tendon damage and rupture - classically achilles
Lowers seizure threshold
what are 5 complications of epididymo-orchitis?
Chronic pain
chronic epidiymitis
testicular atrophy
subfertility/infertility
Scrotal abscess
what sign can distinguish testicular torsion from epididymo-orchitis?
Prehn sign
Pain relived on elevation of scrotum
what is the management of unknow STI in epididymo-orchitis?
Ceftriaxone 500mg IM
PLUS
Doxycycline 100mg PO BD 10-14 days
what is acute interstitial nephritis?
inflammation oedema and infiltration of connective tissues between renal tubules
what re 3 causes of acute interstitial nephritis?
Drugs - most common
Systemic disease - SLE, sarcoidosis, Sjogren’s syndrome
Infection - hanta virus, staphylococci
what are 6 medications that can cause acute interstitial nephritis?
Penicillin
Rifampicin
NSAIDs
Allopurinol
Furosemide
PPIs
what are 4 features of acute interstitial nephritis?
Fever, rash, arthralgia
Eosinophilia
Mild renal impairment
Hypertension
what are 3 urine dip/MCS results in acute interstitial nephritis?
High WCC WITHOUT infection
White cell casts
Protein
what is the gold standard investigation for acute interstitial nephritis?
Renal biopsy
what is renal tubular acidosis?
Metabolic acidosis due to pathology in renal tubules which balance H+ and HCO3- ions to maintain blood pH
what is type 1 renal tubular acidosis?
Distal tubule cannot excrete H+ ions
Leads to high urinary pH
Lead to LOW serum potassium
what is type 2 renal
tubular acidosis?
Proximal tubule cannot reabsorb bicarb
urinary pH = HIGH
Serum potassium = LOW
what is type 4 renal
tubular acidosis?
Low aldosterone or impaired aldosterone function
Urinary pH = LOW
Serum potassium = HIGH
what is the most common type of renal
tubular acidosis?
Type 4
what is classed as high urinary pH?
pH >6
what are 3 features of type 1 renal
tubular acidosis?
High urinary pH - due to absence of H+ ions
Metabolic acidosis - due to retained H+ ions
Hypokalaemia - due to failure of H+/K+ATPase
what are 7 causes of type 1 renal
tubular acidosis?
genetic
SLE
Sjogren’s
Primary biliary cholangitis
Hyperthyroidism
Sickle cell anaemia
Marfan’s
what is the management of types 1 and 2 renal
tubular acidosis?
oral bicarb
what is the presentation of type 2 renal
tubular acidosis?
High urinary pH - excess bicarb in urine
Metabolic acidosis - inadequate bicarb retention
Hypokalaemia - urinary loss of potassium with bicarb
what are 3 causes of type 2 renal
tubular acidosis?
Inherited
Multiple myeloma
Fanconi’s syndrome
what is the pathophysiology o f type 4 renal
tubular acidosis?
Aldosterone usually stimulates sodium reabsorption and potassium and H+ excretion in distal tubules
when aldosterone dysfunctional there is increased potassium and H+ retention
Hyperkalaemia also suppresses ammonia production in distal tubule which usually buffers H+ ions in urine leading to acidic urine
what is the presentation of type 4 renal
tubular acidosis?
Metabolic acidosis - due to retained H+ ions
Hyperkalaemia - due to retained potassium
Low urinary pH - due to reduced ammonia
what are 3 causes of type 4 renal
tubular acidosis?
Adrenal insufficiency
Diabetic nephropathy
Meds - ACEi, spiro, eplerenone
what is the management of type 4 renal
tubular acidosis?
Manage underlying
Fludrocortisone
Oral bicarb
Hyperkalaemia management
what type of metabolic acidosis is seen in renal
tubular acidosis?
hyperchloremic metabolic acidosis with normal anion gap
what is the most common intrarenal cause of AKI?
Acute tubular necrosis
what is Acute tubular necrosis?
necrosis of the renal tubular epithelial cells severely affecting the functioning of the kidneys
what are the 2 main causes of Acute tubular necrosis?
Ischaemia
Nephrotoxicity - med and rhabdo
what are 10 drugs that can cause acute tubular necrosis?
Aminoglycosides - gent
Acyclovir
Sulfa drugs
Cisplatin
Radiocontrast medium
tacrolimus and ciclosporin
IVIG
Ethylene glycol
Lead
Myoglobin
what is seen on urine MCS in Acute tubular necrosis?
muddy brown casts
what is urine sodium like in acute tubular necrosis vs pre-renal AKI?
ATN >40 mmol/L
PR-AKI >20 mmol/L
why is serum sodium high and urine sodium low in pre-renal AKI?
Kidneys hold on to sodium to preserve water and circulating volume
what is urine osmolality like in acute tubular necrosis vs pre-renal AKI?
ATN <350 mOsm/Kg
PR-AKI >500 mOsm/Kg
what is fractional sodium excretion like in acute tubular necrosis vs pre-renal AKI?
ATN >1%
PR-AKI <1%
what is serum urea: creatinine ration like in acute tubular necrosis vs pre-renal AKI?
ATN = normal
PR-AKI = raised
what are 9 causes of glomerulonephritis?
IgA nephropathy
Membranous nephropathy
Membranoproliferative glomerulonephritis
Post-streptococcal glomerulonephritis
Rapidly progressive glomerulonephritis
Goodpasture syndrome
Henoch-schonlein purpura
Vasculitis - microscopic polyangiitis or granulomatosis with polyangiitis
Lupus nephritis
what antibodies are present in goodpastures syndrome?
Anti-glomerular basement membrane antibodies
what are 2 antibodies present in microscopic polyangiitis?
p-ANCA or MPO antibodies
what are 2 antibodies present in granulomatosis with polyangiitis?
c-ANCA or PR3 antibodies
what is Alport syndrome?
genetic condition leading to defects in type IV collagen needed in the glomerular basement membrane, cochlear, retina and cornea
what is the inheritance of Alport syndrome?
X-linked dominant
what ae 5 features of Alport syndrome?
microscopic haematuria
progressive renal failure
bilateral sensorineural deafness
lenticonus - protrusion of lens into anterior chamber
what is seen on renal biopsy in Alport syndrome?
splitting of lamina densa on electron microscopy resulting in basket weave appearance
what is Rhabdomyolysis?
breakdown of skeletal muscle due to myocyte apoptosis leading to AKI
what are 4 things released in Rhabdomyolysis?
Myoglobin
Potassium
Phosphate
Creatinine Kinase
what breakdown product in Rhabdomyolysis is particularly toxic in high concentrations?
myoglobin
what are 5 causes of Rhabdomyolysis ?
Prolonged immobility/long lie
Extremely rigorous exercise
Crush injuries
Seizures
Statins
what are 8 presentations of Rhabdomyolysis ?
Muscle pain
muscle weakness
muscle swelling
Oliguria
Red-brown urine
Fatigue
Nausea and vomiting
Confusion
what are 4 investigations for Rhabdomyolysis?
Creatinine kinase - raised 3x upper limit
Urine dip +ve for blood - myoglobinuria
U+Es deranged
ECG - for hyperkalaemia
what is the management of Rhabdomyolysis ?
IV fluids
Correct hyperkalaemia
Dialysis if needed
what are 4 medical indications for circumcision?
phimosis
recurrent balantitis
balanitis xerotica obliterans
paraphimosis
what is paraphimosis?
foreskin is retracted behind glans penis and stuck there leading to vascular engorgement and oedema of distal glans
what are 6 types of urinary incontinence?
Stress
urge
overflow
fistulae
functional
mixed
what is urge incontinence?
caused by overactivity of detrusor muscle meaning people feel the sudden need to pass urine
what is stress incontinence?
due to weakness of the pelvic floor and sphincter muscles urine to leaks at times of increased pressure on the bladder like laughing , coughing or surprise
what is overflow incontinence?
occurs with chronic urinary retention (more common in men) and without the urge to pass urine can be due to anticholinergic meds, fibroids, pelvic tumours and neuro conditions
what are 4 causes of overflow incontinence?
Idiopathic
neurogenic
infective
bladder outlet obstruction
what are 8 risk factors for urinary incontinence in ?
increased age
Previous pregnancies and vaginal deliveries
Postmenopausal
obesity
pelvic organ prolapse
Pelvic floor surgery
Neurological disorder
Cognitive impairment and dementia
what are 4 investigations for urinary incontinence?
urinalysis
urodynamic tests
bladder diary
post void residual bladder volume
what is the gold standard investigation of urinary incontinence?
urodynamic testing
what is measured in urodynamic testng?
cystometry - detrusor muscle contraction and pressure
Uroflometry - flow rate
leak point pressure - pressure at which leakage occurs
poist voidal residual bledder volume
video urodynamic testing
what are 3 differential of urinary incontinence?
UTI
pregnancy
urogenital fistula
what are 5 lifestyle managements of stress incontinence
avoid caffeine
avoid smoking
weight loss
reduce fluid intake
pelvic floor training - for 3 months before considering surgery
What is the first line medication to manage stress incontinence?
Duloxetine - only if surgery is not preferred
What are 3 contra-indications to duloxetine?
hepatic impairment
severe renal impairement (<30 creatinine clearance)
Uncontrolled hypertension
what are 4 surgeries for stress incontinence?
tension-free vaginal tape
autologous rectus fascial sling
colosuspension
intramural urethral bulking
what is the management of urge incontinence?
bladder retraining for 6 weeks
anticholinergic medication
surgery - if medical treatment fails
what are 3 examples of anticholinergic medications for urge incontinence?
Oxybutynin
tolterodine
darifenacin
what are 4 anticholinergic side effects?
dry mouth and eyes
constipation
urinary retention
cognitive decline
what are 4 invasive options for urge incontinence?
Botulinum toxin type A - botox - injection in bladder wall
percutaneous sacral nerve stimulation
augmentation cystoplasty
urinary diversion
what is one non-anticholinergic that can be used to treat urge incontinence?
Mirabegron - useful in elderly with risk of side effects of anticholinergics
CAN CAUSE HYPERTENSIVE CRISIS!!
what is acute urinary retention?
when a person suddenly over a period of hour or less becomes unable to voluntarily pass urine
what are 6 causes of urinary retention?
BPH
Urethral stricutres
caliculi
cystocele
constipation
masses
Neurological - MS, cauda equina
Medications - anticholinergics
what is the presentation of acute urinary retention?
inability to pass urine
lower abdo pain/discomfort
acute confusional state
palpable distended bladder
what volume is considered acute urinary retention?
> 300ml
what are 2 complications of chronic urinary retnetion?
hydronephrosis and impaired renal function
decompression haematuria - does not require tx
what are 7 side effects of erythropoietin?
accelerated HTN
bone aches
flu like symptoms
skin rashes, urticaria
pure red cell aplasia
iron deficiency anaemia
what cell secrete EPO?
interstitial cells in peritubular capilary bed of renal cortex
what are 5 indications for acute dialysis?
AEIOU
Acidosis - severe and unresponsive
Electrolyte abnormalities - treatment resistant
Intoxication - overdose
Oedema - severe and unresponsive
Uraemia symptoms
what are the 2 different types of peritoneal dialysis?
continuous ambulatory
automated - overnight with machine
what are 8 complications of haemodialysis?
site infection
endocarditis
stenosis at site
hypotension
cardiac arrhythmia
air embolus
anaphylaxis
disequilibriation syndrome
what are 10 complications of peritoneal dialysis?
peritonitis
sclerorsing peritonitis
catheter infection
catheter blockage
constipation
fluid retention
hyperglycaemia
hernias
back pain
malnutrition
what are 8 complications of renal transplant?
DVT/PE
opportunistic infection
malignancies - lymphoma and skin cancer
bone marrow suppression
recurrence of original disease
Urinary tract obstruction
cardiovascular disease
graft rejection
what is used to prevent blood clotting in haemodialysis?
heparin
how often are patients with diabetes screened for diabetic nephropathy?
yearly albumin:creatinine ratio - >2.5 = microalbuminuria
what is the management of diabetic nephropathy?
dietary protein restriction
tight glycemic control
BP control
ACE inhibitors or ARBs - if urinary ACR >3 mg/mmol
Statins
what is cardiorenal syndrome?
acute or long term dysfunction in one organ inducing acute or long term dysfunction of the other
what are 7 risk factors for cardiorenal syndrome?
elderly
comorbid conditions
meds - NSAIDS, diuretics, ACEI, aldosterone receptor antagonists
Hx of HF
prior MI
Elevated cardiac troponin
CKD
