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Phase 4 > Renal/Uro > Flashcards

Renal/Uro Flashcards

1
Q

what is interstitial cystitis?

A

chronic inflammation of the urinary bladder- aka bladder pain syndrome or hypersensitive bladder syndrome

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2
Q

what are the top 3 causative organisms for cystitis?

A

E.Coli - most common
Staph saprophyticus
Klebsiella pneumoniae

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3
Q

what is the presentation of interstitial cystitis?

A

> 6 weeks of

Suprapubic pain
frequency of urination
urgency of urination
symptoms may be worse during menstruation

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4
Q

what are 2 things that may be seen on cystoscopy in interstitial cystitis?

A

Hunner lesions - red inflamed patches of bladder mucosa

Granulations - tiny haemorrhages in bladder wall

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5
Q

what is the management of interstitial cystitis?

A

supportive management - diet, smoking, bladder retraining, CBT

Analgesia, antihistamines, anticholinergics

Intravesical medications (direct to bladder) - lidocaine, etc

Hydrodistension and surgery

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6
Q

What are 6 voiding LUTS?

A

weak stream
splitting or spraying, intermittency
hesitancy
straining
Terminal dribbling
incomplete emptying

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7
Q

What are 6 storage LUTS?

A

Frequency
Urgency
Nocturia
Urge incontinence
stress incontinence
leaking

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8
Q

what is the pathophysiology of BPH?

A

there is hyperplasia in the glandular epithelial and stromal cells of the prostate due to increased action of 5-alpha reductase

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9
Q

what are 5 risk factors for BPH?

A

Increasing age - 50+
FHx
Obesity
Afro-Caribbean
Diabetes

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10
Q

what are 3 manifestations of BPH?

A

Voiding LUTS
Storage LUTs
Urinary retention - lower abdo pain, inability to urinate

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11
Q

what are 4 initial investigation for BPH?

A

Urinalysis
PSA
U+E - may cause renal failure in obstruction
DRE

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12
Q

what is the conservative management of BPH?

A

treat constipation
reduce caffeine and fluid intake
medication review
retrain bladder

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13
Q

what is the pharmacological managements of BPH?

A

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

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14
Q

what are 6 indications for surgical management of BPH?

A

RUSHES

Recurrent refractory retention
UTIs, Recurrent
Stones in bladder
Haematuria, refractory
Elevated creatinine due to bladder outflow obstruction
Symptoms despite max medical therapy

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15
Q

What are 3 surgical managements of BPH?

A

Transurethral incision of prostate <30g
Transurethral resection of prostate 30-80g
Open prostatectomy >80g

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16
Q

what are 5 complications of BPH?

A

urinary retention
UTIs
bladder stones
renal dysfunction
haematuria

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17
Q

what are 3 complications of BPH surgery?`

A

retrograde ejaculation
erectile dysfunction
TURP syndrome - life threatening triad of fluid overload, dilutional hyponatraemia and neurotoxicity

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18
Q

What hormone does the prostate secrete?

A

Dihydrotestosterone

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19
Q

What is Chronic Kidney Disease?

A

Progressive deterioration in renal function, present for ≥3 months, with implications for health

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20
Q

what is the GFR value for CKD?

A

<60 ml/min/1.73 m2

At least 2 readings separated by at least 90 days

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21
Q

what is stage 1 CKD?

A

eGFR >90 PLUS evidence of renal damage

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22
Q

what is stage 2 CKD?

A

eGFR 60-89 PLUS evidence of renal damage

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23
Q

what is stage 3A CKD?

A

eGFR 45-59 ml/min/1.73m2

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24
Q

what is stage 3B CKD?

A

eGFR 30-44 ml/min/1.73m2

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25
Q

what is stage 4 CKD?

A

eGFR 15-29 ml/min/1.73m2

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26
Q

what is stage 5 CKD?

A

eGFR <15 ml/min/1.73m2

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27
Q

what are 6 finding that can evidence renal damage?

A

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

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28
Q

what are 6 causes of CKD?

A

Diabetes - 1/3rd of people with DM
HTN
Polycystic kidney disease
Medications - NSAIDs, Lithium
Chronic Glomerulonephritis or pyelonephritis

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29
Q

What are 5 early manifestations of CKD?

A

asymptomatic in early stages

Fatigue - due to toxin build up and anaemia due to reduced EPO

Polyuria or nocturia

HTN

Puffiness or swelling

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30
Q

what are 8 later manifestations of CKD?

A

Decreased urine output
Fluid overload
Uraemic symptoms
Neuro symptoms - fatigue to seizures
Cardio symptoms
Anaemia symptoms
Bone and mineral disease
Metabolic acidosis

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31
Q

What are 6 symptoms of uraemia?

A

nausea and vom
anorexia
metalic taste in mouth
hiccups
pruritus

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32
Q

what are 3 investigations for CKD?

A

eGFR
Albumin creatinine ratio - urine spot sample - >3mg/mmol = proteinuria

FBC

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33
Q

what is the difference between CKD and AKI on renal US?

A

CKD = usually small b/l kidneys

other than if due to
- autosomal dominant polycystic kidney disease
- diabetic nephropathy
- amyloidosis
- HIV associate

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34
Q

who in AKI should have a renal US?

A

if no identifiable cause or at risk of obstruction => US within 24 hours

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35
Q

when should you refer to renal in CKD? 3

A

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

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36
Q

what is the name of the formula that can be used to calculate eGFR?

A

Modification of diet in renal disease equation

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37
Q

what is the management for CKD?

A

Lifestyle advice - smoking, exercise, nephrotoxins, low salt and potassium diet

Optimise diabetic control
optimise HTn control
Reduce/avoid nephrotoxic drugs
Treat glomerulonephritis

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38
Q

How is anaemia managed in CKD?

A

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

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39
Q

what is the management of bone disease in CKD?

A

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

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40
Q

why does CKD cause bone disease?

A

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

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41
Q

what is one sign of CKD bone disease on x-ray?

A

Rugger jersey spine on spinal X-ray

Sclerosis of both ends of vertebral body (more white) and osteomalacia (less white) in the central vertebrae

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42
Q

what is the 1st line management of HTN in CKD with proteinuria?

A

ACEi

Need close potassium monitoring

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43
Q

How should CVD risk be managed in CKD?

A

ACEi - for HTN + Proteinuria or Diabetes

Furosemide if eGFR <45 as lowers serum potassium

Atorvostatin 20mg for prevention

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44
Q

what SGLT-2 inhibitors are used in CKD?

A

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

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45
Q

what equation can be used to estimate 5 year risk of kidney failure requiring dialysis?

A

Kidney failure risk equation

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46
Q

what are 5 complications of CKD?

A

anaemia - normochromic, normocytic
CKD metabolic bone disease
Cardiovascular disease
End stage kidney disease
Secondary hyperparathyroidism

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47
Q

what type of anaemia is seen in CKD?

A

Normocytic normochromic

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48
Q

what percentage of CO do the kidneys receive?

A

25%

- 1000 ml/min

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49
Q

What is an epididymal cyst?

A

smooth, extratesticular spherical cyst in head of epididymus

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50
Q

what do epididymal cysts look like?

A

Contain clear or milky (spermatocele) fluid
Transluminate
Lie above and behind the testis
testis palpable and separate from cyst

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51
Q

what are 3 differentials for epididymal cyst?

A

spermatocele
hydrocele
varicocele

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52
Q

what is nephrotic syndrome?

A

the presence of proteinuria, hypoalbuminaemia, and peripheral oedema often caused by sclerosis of the podocytes

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53
Q

what are the 4 different nephrotic syndromes?

A

minimal change disease
focal segmental glomerulosclerosis
membranous nephropathy
Membranoproliferative glomerulonephritis

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54
Q

what are the 5 features of nephrotic syndromes?

A
  1. Proteinuria (> 3.5 g/day)
  2. Hypoalbuminemia(< 30 g/L) which leads tooedema
  3. Hyperlipidaemia as the liver increases synthesis of lipids in response to low albumin
  4. Hypogammaglobulinemia: due to loss of immunoglobulin in the urine
  5. Hypercoagulability: due to loss of antithrombin III, and protein C and S in the urine
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55
Q

what is there not in nephrotic syndromes?

A

HAEMATURIA

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56
Q

what are 5 general manifestations of nephrotic syndromes?

A 
hypertension 
frothy urine (lipids)
facial and peripheral oedema
recurrent infections 
predisposition to thrombotic events
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57
Q

what are 4 investigations for nephrotic syndromes?

A

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

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58
Q

what is the most common nephrotic syndrome affecting children?

A

Minimal change disease

M>F

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59
Q

what might minimal change disease be preceded by?

A

a upper respiratory tract infection

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60
Q

what cancer is associated with minimal change disease?

A

Hodgkin’s lymphoma

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61
Q

what 3 things can trigger minimal change disease?

A

recent infection
recent vaccination
immune stimulus

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62
Q

what are 3 risk factors for minimal change disease?

A

Hodgkin’s lymphoma
leukaemia
Hep B/C

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63
Q

what is the pathophysiology of minimal change?

A

T cells release cytokines-glomerular-permeability factor => flattens out podocytes (effacement) so they fuse together => allow albumin (but not immunoglobulins) into nephron => selective proteinuria

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64
Q

what are 3 investigations of minimal change disease?

A

urinalysis - red cast and oval bodies
24-hour urine protein - high
serum albumin - low

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65
Q

what are 3 differentials for minimal change?

A

acute glomerulonephritis
focal segmental glomerulosclerosis
congestive HF

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66
Q

what is the management for minimal change disease?

A

corticosteroids - prednisolone!!!

fluid restriction and low salt diet
immunosuppressants

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67
Q

what are 3 complications of minimal change disease?

A

spontaneous peritonitis
thrombosis
relapse in adulthood

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68
Q

what is the most common cause of nephrotic syndrome is adults of African or hispanic descent?

A

Focal segmental glomerulosclerosis

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69
Q

what are 4 potential causes of focal segmental glomerulosclerosis?

A

heroine use
HIV infection
sickle cell disease
SLE

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70
Q

what is seen on light microscopy in focal segmental glomerulosclerosis?

A

sclerosis and hyalinosis

only parts of some glomeruli are affected

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71
Q

what are 4 causes of membranous nephropathy?

A

SLE
Drugs - NSAIDS, gold
infection - Hep B/C, syphilis
tumours

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72
Q

is focal segmental glomerulosclerosis a nephrotic or Nephritic?

A

nephrOtic

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73
Q

is minimal change disease nephrotic or nephritic?

A

nephrOtic

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74
Q

what is seen histologically in membranous nephropathy?

A

diffuse capillary and basement membrane thickening due to immune complex deposition
spike and dome pattern of basement membrane

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75
Q

what are two conditions that can cause nephropathy?

A

amyloidosis

diabetes

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76
Q

what is nephrolithiasis?

A

kidney stones

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77
Q

what are 6 risk factors for renal stones?

A

Male
Prev stones
Dehydration
Hypercalcaemia, hypercalciuria, hyperparathyroid
Renal tubular acidosis
Gout - for urate stones

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78
Q

what are 4 drugs that increase risk of renal stones?

A

Loop diuretics - furosemide
Steroids
Acetazolamide
Theophylline

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79
Q

what is the most common composition of renal stones?

A

calcium oxalate

black/dark brown stones, more likely to form in acidic urine
radiopaque

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80
Q

what are struvite renal stones associated with?

A

UTI

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81
Q

what can struvite renal stones cause?

A

Staghorn caliculi - branching calcifications due to recurrent UTIs

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82
Q

what type of renal stones are radiolucent?

A

Uric acid

Associated with gout and malignancy

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83
Q

what causes cysteine renal stones?

A

Cystinuria in autosomal recessive cystinuria disorder

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84
Q

what are 5 manifestations of renal stones?

A

Loin to groin severe renal colic

Haematuria
Nausea and vomiting
reduced urine output
Symptoms of sepsis/infection

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85
Q

what are 3 investigations for renal stones?

A

non-contrast CT kidney, ureter and bladder - GOLD
urinalysis - haematuria
U+Es - raised creatinine - AKI due to obstruction

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86
Q

what is the 1st line investigation for renal stones?

A

Urinalysis - haematuria

bloods -inflammatory markers, u+e, bone profile and urate

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87
Q

what is the gold standard for renal stones and how quickly should it be done?

A

Non-contrast CT KUB

within 14 hours of admission or immediately in sepsis or one kidney

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88
Q

what is the initial management of renal stones?

A

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

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89
Q

what analgesia is given in renal stones?

A

1 - IM diclofenac

2 - IV paracetamol if NSAIDs contraindicated

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90
Q

what is the management for renal stones <5mm?

A

watchful waiting

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91
Q

what is the management of renal stones 5-10mm?

A

Shockwave lithotripsy

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92
Q

what is the management of renal stones 10-20mm?

A

Shock wave lithotripsy or ureteroscopy

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93
Q

what is the management of renal stones >20mm?

A

percutaneous nephrolithotomy

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94
Q

what are 6 strategies for preventing renal stones?

A

Increase fluid intake
add lemon juice to drinking water
avoid carbonated drinks
limit salt intake
potassium citrate
thiazide diuretics

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95
Q

what are 5 complications of renal stones?

A

obstruction and hydronephrosis
Urethral strictures
Infection and urosepsis
CKD and AKI
Recurrence

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96
Q

what is testicular torsion?

A

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.

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97
Q

what deformity makes testicular torsion more likely?

A

Bell clapper - testicle lies in more horizontal position and has improper attachment of tunica vaginalis

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98
Q

what are 5 risk factors for testicular torsion?

A

Young age - peak incidence 13-15 years
Trauma/exercise
undescended testicles
Bell-clapper deformity

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99
Q

what are 5 manifestations of testicular torsion?

A

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

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100
Q

what are 4 investigations for testicular torsion?

A

US testicle - fluid and whirlpool sign

power doppler ultrasound - decreased blood flow
colour doppler ultrasound - decreased blood flow
surgical exploration - gold

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101
Q

what sign might be seen on USS of the testicles in testicular torsion?

A

whirlpool sign - spiral appearance of spermatic cord and blood vessels

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102
Q

what is the management for testicular torsion?

A

nil by mouth
analgesia
urgent senior urology assessment
surgical exploration of scrotum
Bilateral orchiopexy
orchidectomy if needed

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103
Q

what is urethritis?

A

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

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104
Q

what are 4 organisms that cause urethritis?

A

Chlamydia trachomatis - gram -ve - most common
N. gonorrhoea - gram -ve diplococci
Mycoplasma genitalium
ureaplasma urealyticum

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105
Q

what are 3 risk factors for urethritis?

A

15-24 years
multiple sexual partners/new sexual partner
unprotected sex

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106
Q

what are 5 manifestations of urethritis?

A

may be asymptomatic

acute urethral discharge following unprotected sex
irritation/itching
dysuria
orchalgia/pelvic pain
no rash or arthritis

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107
Q

what are 2 investigations for urethritis?

A

Nucleic acid amplification test

Gram stain, microscopy and culture of urethral discharge/urine sediment

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108
Q

what are 3 complications of uretheritis?

A

epididymitis
subfertility
reactive arthritis

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109
Q

what is the management of urethritis?

A

Doxycycline 100mg BD 7 days
THEN
Azithromycin 1g stat then 500mg BD for 2 days

NO DOXY IN PREGNANCY

Test of cure

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110
Q

what is the 1st and 2nd line treatment for chlamydia ?

A

1 - Doxycycline

2 - Azithromycine

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111
Q

what are 3 complications of urethritis?

A

reactive arthritis
gonococcal conjunctivitis
prostatitis

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112
Q

what is the most common causative organism of uncomplicated UTIs?

A

E. Coli

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113
Q

what is classed as an uncomplicated UTI?

A

Caused by typical uropathogens in non-pregnant women with no known anatomical or functional abnormalities of the urinary tract

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114
Q

what is classed as a recurrent UTI?

A

2+ UTIs in 6 months or 3 + in one year

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115
Q

what are the 5 organisms that most often cause UTIs?

A

KEEPS

klebsiella pneumoniae
E. coli
Enterococci
Proteus aprophyticus
Staphylococcus saprophytic - coagulase -ve

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116
Q

what are 9 risk factors for UTIs?

A

Sexual activity
Female
post-menopausal
Pregnancy - physiological urinary statsis and vesicoureteral reflux
Catheters
BPH/Prostitis
Dysfunctional voiding
Anatomical abnormalities - vesicoureteral reflux, renal stones
Immunosupression

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117
Q

what are 7 manifestations of UTIs?

A

Dysuria
Frequency
Urgency
Cloudy/offensive smelling urine
Haematuria
Lower abdo pain
Fever - low grade
malaise

acute confusion in elderly

118
Q

what are 3 investigations for UTI?

A

urine dipstick - + nitrates and leukocytes
Urine MSU for MCS - always in complicated patients

119
Q

what is the management of uncomplicated UTI?

A

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

120
Q

when should women with haematuria be referred 2ww to urology?

A

> 45 with visible haematuria after successful UTI treatment
60 with unexplained non-visible haematuria and either and either dysuria or raised WCC

121
Q

when should women with recurrent UTIs be referred to Uro?

A

> 60 years recurrent or persistent unexplained UTI
40 and no know cause

122
Q

what are 5 self care measures women can take to prevent UTI?

A

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

123
Q

what antibiotics can be used as prophylaxis in recurrent uncomplicated UTI?

A

1 - trimethoprim 100mg at night
OR Nitrofurantoin 50-100mg

2 - amoxicillin 250mg at night
OR cefalexin 125mg at night

124
Q

what is the management of UTI in pregnancy?

A

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

125
Q

when should nitrofurantoin be avoided in pregnancy?

A

3rd trimester due to risk of neonatal haemolysis

126
Q

when should trimethoprim be avoided in pregnancy?

A

1st trimester works as a folate antagonist - congenital malformations, neural tube defects

127
Q

How should asymptomatic bacteriuria in pregnancy be managed?

A

immediately with same ABx as UTI - due to risk of progression to pyelo

128
Q

How long should complicated UTIs be treated for?

A

7 days

129
Q

what is a contraindication to nitrofuranoin?

A

eGFR <45

also avoid in 3rd trimester pregnancy

130
Q

what are 5 complications of UTI?

A

Acute/chronic pyelonephritis
Urosepsis
Renal/peri-renal abscess
AKI
Increased risk pre-term delivery in pregnancy

131
Q

what is varicocele?

A

the abnormal dilation of the internal spermatic veins and pampiniform plexus that drain blood from the testis caused by venous reflux

132
Q

which teste is varicocele most common in?

A

left - due to increased resistance in L testicular vein which drains into L renal vein whereas R testicular vein drains into IVC

133
Q

what are 2 risk factors for varicocele?

A

somatic factors - tall/ low BMI

134
Q

what are 6 manifestations of varicocele?

A

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

135
Q

when should varicoceles be referred for urgent investigation?

A

if do not disappear on lying - may be due to retroperitoneal tumours obstructing renal vein drainable

136
Q

what can be used to confirm diagnosis of varicocele?

A

US doppler
Semen analysis
Hormonal testing

137
Q

what is one possible surgical intervention for varicocele?

A

Surgery or endovascular embolization

138
Q

what are 3 complications of varicocele?

A

Infertility
Testicular atrophy
Pain

139
Q

what is nephritic syndrome?

A

inflammation of the glomerular basement membrane leading to haematuria and limited proteinuria

140
Q

what are the 6 different types of nephritic syndromes?

A 
post-streptococcal glomerulonephritis
IgA nephropathy
diffuse proliferative glomerulonephritis
membranoproliferative glomerulonephritis 
rapidly progressing glomerulonephritis
alport syndrome
141
Q

which 3 nephritic syndromes are caused by type III hypersensitivity?

A

post-streptococcal glomerulonephritis
IgA nephropathy
Diffuse proliferative glomerulonephritis

142
Q

what are 5 manifestations of nephritic syndromes?

A 
haematuria
proteinuria < 3.5g/day
arterial hypertension 
peripheral and peri-orbital oedema 
decreased urine output
143
Q

what are 3 investigations for nephritic syndromes?

A

bloods - increased creatinine and blood urea nitrogen
urinalysis - haematuria, RBC cast, proteinuria <3.5g/day
renal biopsy

144
Q

what is the management for nephritic syndromes?

A

immunosuppression - steroids
blood pressure control - ACEi/ARB (furosemide)
statins
omega-3 fatty acids

145
Q

what are 2 complications of nephritic syndromes?

A

AKI

CKD

146
Q

what is post-streptococcal glomerulonephritis?

A

nephritic syndrome occurring after pharyngitis or skin infection caused by streptococcus pyogenes infection

147
Q

what are 3 investigations of post-streptococcal glomerulonephritis?

A

bloods - low levels of C3 and CH50
positive streptozyme test
kidney biopsy

148
Q

what is IgA nephropathy?

A

an autoimmune nephritic syndrome caused by mesangial IgA immune deposits
age 16-35 most commonly

149
Q

what is the most common nephritis?

A

IgA nephropathy

150
Q

what are 4 risk factors for IgA nephropathy?

A

male
HIV
FHx
ethnicity - asian

151
Q

what usually precedes IgA nephropathy?

A

upper respiratory tract infection (or less usually gastroenteritis)

152
Q

what is the most common form of lupus nephritis?

A

diffuse proliferative glomerulonephritis - also worst prognosis

153
Q

what are 4 risk factors for membranoproliferative glomerulonephritis?

A

age 8-16
infections
CLL
acquired partial lipodystrophy

154
Q

what can cause rapidly progressive glomerulonephritis?

A

goodpasture’s syndrome

155
Q

what is a fungi that can cause cystitis in the immunosuppressed and those with indwelling catheters?

A

Candida

156
Q

what is xanthogranulomatous pyelonephritis?

A

a chronic kidney infection caused by an infected kidney stone causing obstruction

157
Q

what is the most common causative pathogen of prostatitis?

A

E. coli

158
Q

what is chronic prostatitis?

A

prostatitis lasting >3 months

159
Q

what are 4 risk factors for acute bacterial prostatitis?

A

recent UTI
Urogenital instrumentation
intermittent catheterisation
recent prostate biopsy
HIV
Anal sex

160
Q

what are 5 presentations of prostatitis?

A

Pelvic pain
LUTS
Sexual dysfunction
Pain with bowel movements
Tender and enlarged protate

if acute bacterial may also have fever, myalgia, nausea, fatigue, sepsis

161
Q

what scoring system can be used to assess chronic prostatitis symptoms/

A

national institute of health chronic prostatitis symptom index

162
Q

what are 3 investigations for prostatitis?

A

Urine dip
Urine MCS
Chlamydia and gonorrhoea NAAT

163
Q

what is the management of acute bacterial prostatitis?

A

14 days oral ciprofloxacin (orafloxacin, trimethoprim)

Analgesia
Laxatives

Admission if required

164
Q

what are 5 management options for chronic prostatitis?

A

Alpha blockers - tamsulosin
analgesia
Psychological treatment
Abx
Laxatives

165
Q

what are 4 complications of prostatitis?

A

acute urinary retention
chronic prostatitis
prostatic abscess
sepsis

166
Q

what is prehn’s sign and what conditions is it positive in?

A

pain relief with lifting affected testicle

positive in orchitis and epididymitis
NEGATIVE IN TORSION

167
Q

what 2 genes are affected in autosomal dominant polycystic kidney disease?

A

PKD1 and PKD2

on chromosome 16 and 4 respectively

168
Q

what is the presentation of autosomal dominant polycystic kidney disease?

A

haematuria
loin pain
hypertension
recurrent UTIs
Kidney stones
SAH
palpable kidneys/mass

169
Q

what is the criteria for diagnosis of autosomal dominant polycystic kidney disease on US?

A

<30 years - 2 cystic unilateral or b/l
>30 - 2 cysts in each kidney
>60 - 4 cysts in each kidney

170
Q

what are 4 extrarenal manifestations of autosomal dominant polycystic kidney disease?

A

Cerebral aneurysm - berry
Hepatic, splenic, pancreatic, ovarian, prostatic cysts
Mitral regurgitation
Colonic diverticula

171
Q

what cardiac condition is associated with autosomal dominant polycystic kidney disease?

A

mitral regurg

172
Q

what are 6 complications of autosomal dominant polycystic kidney disease?

A

chronic loin/flank pain
hypertension
fross haematuria
recurrent UTIs
Renal stones
end stage renal failure around 50 years

173
Q

is autosomal dominant or recessive polycystic kidney disease more common?

A

dominant

recessive is more severe but less common

174
Q

what is the presentation of autosomal recessive polycystic kidney disease?

A

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

175
Q

what medication can be used to slow development of cysts in autosomal dominant polycystic kidney disease?

A

Tolvaptan - vasopressin receptor antagonist

176
Q

where in the brain is the micturition centre?

A

the pons

177
Q

berry aneurysms are a complication of what renal disease?

A

autosomal dominant polycystic kidney disease

178
Q

What is the treatment for syphilis?

A

Benzanthine Penicillin and Azithromycin

179
Q

when is trimethoprim most teratogenic?

A

1st trimester

180
Q

when is nitrofurantoin not recommended in pregnancy?

A

3rd trimester

181
Q

what s oxybutynin used for?

A

overactive bladder

182
Q

is there hyperlipidaemia in nephritic syndromes?

A

NO!!! only nephrotic

183
Q

what condition can cause muddy brown casts on urinalysis?

A

acute tubular necrosis

184
Q

what are the 6 functions of the kidney?

A

Fluid volume management
Waste excretion and selective reabsorption
RBC production
Vitamin D metabolism
Acid-base regulation
Blood pressure management

185
Q

what is glomerulonephritis?

A

any of a group of diseases that injure the part of the kidney that filters blood (the glomeruli).

186
Q

what are the characteristic finding is nephritic syndromes?

A

oedema
proteinuria
decreased protein and increased lipids in blood

187
Q

what are the characteristic features of nephritic syndromes?

A

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

188
Q

what are the criteria for the 2 week wait for bladder cancer?

A

45+ with unexplained visible haematuria without UTI

60+ with unexplained non-visible haematuria and either dysuria or a raised WCC

189
Q

what percentage of men with raised PSA will not have prostate cancer?

A

specificity = 30%

190
Q

what percentage of men with normal PSA will have prostate cancer?

A

sensitivity = 94%

191
Q

what is erectile dysfunction?

A

the persistent inability to attain and maintain an erection to permit satisfactory sexual performance

192
Q

what are 10 risk factors for erectile dysfunction?

A

Older age
obesity
diabetes
dyslipidaemia
metabolic syndrome
hypertension
smoking
alcohol
SSRIs
Beta blockers

193
Q

what is the difference in presentation between organic and psychogenic erectile dysfunction?

A

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

194
Q

what are 3 organic causes of erectile dysfunction?

A

Vasculogenic - most common
Neurogenic - Parkinson’s, stroke, DM
Anatomical/structural

195
Q

what are 2 investigations for erectile dysfunction?

A

QRisk calculated

Free testosterone - 9-11am

196
Q

what is the 1st line treatment for erectile dysfunction?

A

phsophodistesterase-5 inhibiters

SILDENAFIL

197
Q

what is the 1st line management of erectile dysfunction if refusing/unable to take medication?

A

vacuum erection devices

198
Q

what are 3 physical causes of premature ejaculation?

A

Prostitis
hormonal problems - thyroid
Using recreational drugs

199
Q

what are 4 psychological causes of premature ejaculation?

A

depression
stress
relationship problems
anxiety

200
Q

what is the management of premature ejaculation?

A

Psychosexual counselling
SSRIs
Phosphodiesterase-5 inhibitors
Local anaesthetic creams, sprays or condoms
Masturbation before intercourse

201
Q

what is a UTI?

A

bacteria in the urine combined with clinical features

202
Q

when would you refer someone with UTIs for a bladder cancer review?

A

60+ with recurrent/persistent UTIs

203
Q

what are 4 risk factors for pyelonephritis?

A

Female
Structural abnormalities
vesico-ureteric abnormalities
Diabetes

204
Q

what are 4 bacteria that cause pyelonephritis?

A

E. coli - most common
Klebsiella species
proteus mirabilis
pseudomonas species

205
Q

what is the triad of pyelonephritis?

A

loin/back pain (renal angle tenderness)
fever
Nausea/vomiting

206
Q

what is the 1st line management of pyelonephritis?

A

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

207
Q

what are 2 IV Abx for severe pyelonephritiss?

A

Gentamicin

Ciprofloxacin 400mg TDS

208
Q

what is the 1st line pyelonephritis management in pregnancy?

A

Cefalexin 500mg TDS 7-10 days

209
Q

what scan can be done to look for kidney scaring in chronic pyelonephritis?

A

Dimercaptosuccinic acid (DMSA) scan

210
Q

what is the management of epididymal cysts?

A

Observation and scrotal support if needed

Aspiration and sclerotherapy
Surgical excision

211
Q

what is a hydrocele?

A

collection of fluid in the tunica vaginalis that surrounds the testes

212
Q

what is the presentation of hydrocele?

A

Swollen scrotum with testicles palpable inside hydrocele
Soft and fluctuant
Irreducible and no bowel sounds
Transilluminates

213
Q

what are 5 causes of hydrocele?

A

idiopathic

Testicular cancer
testicular torsion
Epididymo-orchitis
trauma

214
Q

what are the 2 different types of hydrocele?

A

Simple - just due to trapped fluid

Communicating - fluid coming from peritoneal cavity via the processus vaginalis leading to fluctuant size

215
Q

what is the management of a simple hydrocele?

A

usually self resolves

216
Q

what is the management of a communicating hydrocele?

A

ligation/removal of processus vaginalis

217
Q

what are 4 causes of epididymo-orchitis?

A

Escherichia coli
Chalmydia trachomatis
Neisseria gonorrhoea
Mumps - often only orchitis

218
Q

what is the presentation of epididymo-orchitis?

A

Gradual onset

Testicular pain
dragging or heavy sensation
swelling of testicle or epididymis
Tenderness on palpation
urethral discharge - chlamydia or gonorrhoea
Systemic symptoms

219
Q

what are 6 investigations for epididymo-orchitis?

A

urine MSC
first pass urine NAAT for chlamydia and gonorrhoea
Charcoal swab
saliva swab for mumps
serum antibodies for mumps
US testicles

220
Q

what is the management of e. coli epididymo-orchitis?

A

Ofloxacin 14 days

Levofloxacin 10 days

Co-amox 10 days - when quinolones contraindicated

221
Q

what are 2 side effects of quinolones?

A

Tendon damage and rupture - classically achilles
Lowers seizure threshold

222
Q

what are 5 complications of epididymo-orchitis?

A

Chronic pain
chronic epidiymitis
testicular atrophy
subfertility/infertility
Scrotal abscess

223
Q

what sign can distinguish testicular torsion from epididymo-orchitis?

A

Prehn sign

Pain relived on elevation of scrotum

224
Q

what is the management of unknow STI in epididymo-orchitis?

A

Ceftriaxone 500mg IM
PLUS
Doxycycline 100mg PO BD 10-14 days

225
Q

what is acute interstitial nephritis?

A

inflammation oedema and infiltration of connective tissues between renal tubules

226
Q

what re 3 causes of acute interstitial nephritis?

A

Drugs - most common
Systemic disease - SLE, sarcoidosis, Sjogren’s syndrome
Infection - hanta virus, staphylococci

227
Q

what are 6 medications that can cause acute interstitial nephritis?

A

Penicillin
Rifampicin
NSAIDs
Allopurinol
Furosemide
PPIs

228
Q

what are 4 features of acute interstitial nephritis?

A

Fever, rash, arthralgia
Eosinophilia
Mild renal impairment
Hypertension

229
Q

what are 3 urine dip/MCS results in acute interstitial nephritis?

A

High WCC WITHOUT infection
White cell casts
Protein

230
Q

what is the gold standard investigation for acute interstitial nephritis?

A

Renal biopsy

231
Q

what is renal tubular acidosis?

A

Metabolic acidosis due to pathology in renal tubules which balance H+ and HCO3- ions to maintain blood pH

232
Q

what is type 1 renal tubular acidosis?

A

Distal tubule cannot excrete H+ ions

Leads to high urinary pH

Lead to LOW serum potassium

233
Q

what is type 2 renal
tubular acidosis?

A

Proximal tubule cannot reabsorb bicarb

urinary pH = HIGH

Serum potassium = LOW

234
Q

what is type 4 renal
tubular acidosis?

A

Low aldosterone or impaired aldosterone function

Urinary pH = LOW

Serum potassium = HIGH

235
Q

what is the most common type of renal
tubular acidosis?

A

Type 4

236
Q

what is classed as high urinary pH?

A

pH >6

237
Q

what are 3 features of type 1 renal
tubular acidosis?

A

High urinary pH - due to absence of H+ ions

Metabolic acidosis - due to retained H+ ions

Hypokalaemia - due to failure of H+/K+ATPase

238
Q

what are 7 causes of type 1 renal
tubular acidosis?

A

genetic
SLE
Sjogren’s
Primary biliary cholangitis
Hyperthyroidism
Sickle cell anaemia
Marfan’s

239
Q

what is the management of types 1 and 2 renal
tubular acidosis?

A

oral bicarb

240
Q

what is the presentation of type 2 renal
tubular acidosis?

A

High urinary pH - excess bicarb in urine

Metabolic acidosis - inadequate bicarb retention

Hypokalaemia - urinary loss of potassium with bicarb

241
Q

what are 3 causes of type 2 renal
tubular acidosis?

A

Inherited
Multiple myeloma
Fanconi’s syndrome

242
Q

what is the pathophysiology o f type 4 renal
tubular acidosis?

A

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

243
Q

what is the presentation of type 4 renal
tubular acidosis?

A

Metabolic acidosis - due to retained H+ ions
Hyperkalaemia - due to retained potassium
Low urinary pH - due to reduced ammonia

244
Q

what are 3 causes of type 4 renal
tubular acidosis?

A

Adrenal insufficiency
Diabetic nephropathy
Meds - ACEi, spiro, eplerenone

245
Q

what is the management of type 4 renal
tubular acidosis?

A

Manage underlying

Fludrocortisone
Oral bicarb
Hyperkalaemia management

246
Q

what type of metabolic acidosis is seen in renal
tubular acidosis?

A

hyperchloremic metabolic acidosis with normal anion gap

247
Q

what is the most common intrarenal cause of AKI?

A

Acute tubular necrosis

248
Q

what is Acute tubular necrosis?

A

necrosis of the renal tubular epithelial cells severely affecting the functioning of the kidneys

249
Q

what are the 2 main causes of Acute tubular necrosis?

A

Ischaemia
Nephrotoxicity - med and rhabdo

250
Q

what are 10 drugs that can cause acute tubular necrosis?

A

Aminoglycosides - gent
Acyclovir
Sulfa drugs
Cisplatin
Radiocontrast medium
tacrolimus and ciclosporin
IVIG
Ethylene glycol
Lead
Myoglobin

251
Q

what is seen on urine MCS in Acute tubular necrosis?

A

muddy brown casts

252
Q

what is urine sodium like in acute tubular necrosis vs pre-renal AKI?

A

ATN >40 mmol/L

PR-AKI >20 mmol/L

253
Q

why is serum sodium high and urine sodium low in pre-renal AKI?

A

Kidneys hold on to sodium to preserve water and circulating volume

254
Q

what is urine osmolality like in acute tubular necrosis vs pre-renal AKI?

A

ATN <350 mOsm/Kg

PR-AKI >500 mOsm/Kg

255
Q

what is fractional sodium excretion like in acute tubular necrosis vs pre-renal AKI?

A

ATN >1%

PR-AKI <1%

256
Q

what is serum urea: creatinine ration like in acute tubular necrosis vs pre-renal AKI?

A

ATN = normal

PR-AKI = raised

257
Q

what are 9 causes of glomerulonephritis?

A

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

258
Q

what antibodies are present in goodpastures syndrome?

A

Anti-glomerular basement membrane antibodies

259
Q

what are 2 antibodies present in microscopic polyangiitis?

A

p-ANCA or MPO antibodies

260
Q

what are 2 antibodies present in granulomatosis with polyangiitis?

A

c-ANCA or PR3 antibodies

261
Q

what is Alport syndrome?

A

genetic condition leading to defects in type IV collagen needed in the glomerular basement membrane, cochlear, retina and cornea

262
Q

what is the inheritance of Alport syndrome?

A

X-linked dominant

263
Q

what ae 5 features of Alport syndrome?

A

microscopic haematuria
progressive renal failure
bilateral sensorineural deafness
lenticonus - protrusion of lens into anterior chamber

264
Q

what is seen on renal biopsy in Alport syndrome?

A

splitting of lamina densa on electron microscopy resulting in basket weave appearance

265
Q

what is Rhabdomyolysis?

A

breakdown of skeletal muscle due to myocyte apoptosis leading to AKI

266
Q

what are 4 things released in Rhabdomyolysis?

A

Myoglobin
Potassium
Phosphate
Creatinine Kinase

267
Q

what breakdown product in Rhabdomyolysis is particularly toxic in high concentrations?

A

myoglobin

268
Q

what are 5 causes of Rhabdomyolysis ?

A

Prolonged immobility/long lie
Extremely rigorous exercise
Crush injuries
Seizures
Statins

269
Q

what are 8 presentations of Rhabdomyolysis ?

A

Muscle pain
muscle weakness
muscle swelling
Oliguria
Red-brown urine
Fatigue
Nausea and vomiting
Confusion

270
Q

what are 4 investigations for Rhabdomyolysis?

A

Creatinine kinase - raised
Urine dip +ve for blood - myoglobinuria
U+Es deranged
ECG - for hyperkalaemia

271
Q

what is the management of Rhabdomyolysis ?

A

IV fluids

Correct hyperkalaemia

Dialysis if needed

272
Q

what are 4 medical indications for circumcision?

A

phimosis
recurrent balantitis
balanitis xerotica obliterans
paraphimosis

273
Q

what is paraphimosis?

A

foreskin is retracted behind glans penis and stuck there leading to vascular engorgement and oedema of distal glans

274
Q

what are 6 types of urinary incontinence?

A

Stress
urge
overflow
fistulae
functional
mixed

275
Q

what is urge incontinence?

A

caused by overactivity of detrusor muscle meaning people feel the sudden need to pass urine

276
Q

what is stress incontinence?

A

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

277
Q

what is overflow incontinence?

A

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

278
Q

what are 4 causes of overflow incontinence?

A

Idiopathic
neurogenic
infective
bladder outlet obstruction

279
Q

what are 8 risk factors for urinary incontinence in ?

A

increased age
Previous pregnancies and vaginal deliveries
Postmenopausal
obesity
pelvic organ prolapse
Pelvic floor surgery
Neurological disorder
Cognitive impairment and dementia

280
Q

what are 4 investigations for urinary incontinence?

A

urinalysis
urodynamic tests
bladder diary
post void residual bladder volume

281
Q

what is the gold standard investigation of urinary incontinence?

A

urodynamic testing

282
Q

what is measured in urodynamic testng?

A

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

283
Q

what are 3 differential of urinary incontinence?

A

UTI
pregnancy
urogenital fistula

284
Q

what are 5 lifestyle managements of stress incontinence

A

avoid caffeine
avoid smoking
weight loss
reduce fluid intake

pelvic floor training - for 3 months before considering surgery

285
Q

What is the first line medication to manage stress incontinence?

A

Duloxetine - only if surgery is not preferred

286
Q

What are 3 contra-indications to duloxetine?

A

hepatic impairment
severe renal impairement (<30 creatinine clearance)
Uncontrolled hypertension

287
Q

what are 4 surgeries for stress incontinence?

A

tension-free vaginal tape
autologous rectus fascial sling
colosuspension
intramural urethral bulking

288
Q

what is the management of urge incontinence?

A

bladder retraining for 6 weeks

anticholinergic medication

surgery - if medical treatment fails

289
Q

what are 3 examples of anticholinergic medications for urge incontinence?

A

Oxybutynin
tolterodine
darifenacin

290
Q

what are 4 anticholinergic side effects?

A

dry mouth and eyes
constipation
urinary retention
cognitive decline

291
Q

what are 4 invasive options for urge incontinence?

A

Botulinum toxin type A - botox - injection in bladder wall
percutaneous sacral nerve stimulation
augmentation cystoplasty
urinary diversion

292
Q

what is one non-anticholinergic that can be used to treat urge incontinence?

A

Mirabegron - useful in elderly with risk of side effects of anticholinergics

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Phase 4 (22 decks)

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