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Medical Conditions > Renal & Urology > Flashcards

Renal & Urology Flashcards

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USMLE® Step 1 flashcards
1
Q

What are the 3 main types of urinary incontinence

A

Stress - involuntray leakage on effort or exertion.
Urgency - involuntary leakage accompanied/ immediately proceeded by sudden compelling desire to pass urine which is difficult to defer.
Mixed - both stress and urgency incontinence. Involuntary leakage associated with both urgency & physical stress/exertion

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2
Q

What is Overflow incontinence?

A

Detrusor under-activity or bladder outlet obstruction results in urinary retention and leakage of urine. Can be caused by chronic urine retention.

There may be straining to urinate or incomplete bladder emptying

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3
Q

What can be an underlying cause continuous urinary incontinence?

A

Urogenital fistula

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4
Q

What are 8 risk factors predisposing one to SUI?

A

Increasing age (most prominent)
pregnancy & vaginal delivery (muscles and connective tissue can be weakened during delivery & damage may occur to pudendal and pelvic nerves)
obesity (increased pelvic pressure on tissues and stretching and weakening of muscles and nerves from excess weight)
Constipation (straining can weaken pelvic floor muscles)
Deficiency in supporting tissues - prolapse, hysterectomy & lack of oestrogen menopause
Family history
Smoking
Drugs eg ACEi - cough -> worsening

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5
Q

How to examine Urinary incontinence?

A

Abdominal ( + DRE) - enlarged bladder, masses, loaded colon, focal impaction & anal tone
Pelvic - prolapsed, atrophy, neurological deficit, retention of urine & pelvic masses

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6
Q

How to examine Urinary incontinence?

A

Abdominal ( + DRE) - enlarged bladder, masses, loaded colon, focal impaction & anal tone
Pelvic - prolapsed, atrophy, neurological deficit, retention of urine & pelvic masses

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7
Q

Which Incontinence is part of overactive bladder syndrome?

A

UUI

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8
Q

What causes the symptoms of overactive bladder syndrome?

A

Involuntary contractions of detrusor muscles during the filling phase of micturition cycle.

The detrusor muscle overactivity can cause urgency and frequency with or without incontinence (dry vs wet OAB)

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9
Q

What are the possible risk factors/ causes for UUI?

A

Women - mostly idiopathic. Associated with systemic neurological conditions eg. Parkinson’s disease, MS or injury to spinal/ pelvic nerves. Local irritation (bladder stones, bladder cancer, infection). Obstruction (BPH), surgery (TURP)

Adverse effects of drugs -> detrusor muscle overactivity eg. parasympathomimetics, antidepressants & HRT

Exacerbations of UUI - caffeinated, acidic or alcoholic drinks

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10
Q

Which medications can cause overflow incontinence?

A

ACEi, antidepressants, antihistamines, antimuscarinics, antiparkinsonian drugs, beta-adrenergic agonists, Calcium channel blockers, opioids & sedatives and hypnotics

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11
Q

Women with systemic neurological disease are more likely to develop with urinary incontinence?

A

Overflow incontinence

Urgency Urinary incontinence (UUI)

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11
Q

Women with systemic neurological disease are more likely to develop which types of urinary incontinence?

A

Overflow incontinence

Urgency Urinary incontinence (UUI)

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12
Q

How can ACEi cause SUI?

A

Side effect = cough -> physical exertion and worsen SUI

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13
Q

What is the prevalence of urinary incontinence?

A

Women > Men (3-11%)

Men suffers mainly from UUI, SUI accounts for <10% and stems mainly from prostate surgery, trauma or neurological injury

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14
Q

Why do more women suffer from urinary incontinence than men?

A

Due to the structural differences in urinary tract, pregnancy, vaginal delivery & menopause

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15
Q

What are the possible complications from UI?

A

Impairment of QoL - employment and leisure activities
Psychological problems - depression, anxiety, embarrassment, isolation, loss of self confidence etc
Social isolation & avoidance of going outside/ places with difficulties going to bathrooms
Sexual problems - reduced intimacy, affection & physical proximity. Women may avoid sexual intercourse if they are concerned
Loss of sleep - particularly in OAB from nocturne
Falls and fractures - esp. in old people
Financial problems - cost of absorbent products and laundry

16
Q

What are the determinants for Prognosis of UI in women?

A

Type of UI, severity and the underlying cause.
Any contributory factors & motivation for treatments.

For a 6-year follow-up study for 42-55 yr old women with UI, over 1/2 had no change in symptoms, 1/3 had decreased incontinence & 15% had worsening symptoms

17
Q

What is included in the assessment of UI in women?

A

Duration, type and severity of UI (frequency), possible complications (psychological, sexual and social isolation), cause & contributing factors

18
Q

What is the modified Oxford grading system for quantifying the strength of contraction for digital pelvic floor muscle examination?

A 
0 = no contraction
1 = flicker. Flicker/ pulsation felt under the examiner's finger
2 = weak. An increase in tension detected, without discernible lift.
3 = moderate. There is a lifting of the muscle belly and also elevation of the posterior vaginal wall
4 = good. Increased tension and good contraction elevate the posterior vaginal wall against resistance (pressure by the examining finger applied to the posterior vaginal wall)
5 = strong. Strong resistance is applied to the elevation of the posterior vaginal wall. The examiner's finger is squeezed and drawn into the vagina
19
Q

What are the 3 main neurological conditions that can cause UI?

A

Parkinson’s disease, Multiple sclerosis, pelvic/ spinal cord injury

20
Q

Which investigation should be done to all women presenting with UI and why?

A

Urinary dipstick analysis - blood, leukocytes, nitrate, pH, glucose & protein

If leukocytes and nitrate present, send sample for MSU - C&S… sign of UTI (treat with antibiotics immediately)

21
Q

How to determine the severity of UI during history taking?

A

Frequency of incontinence, during what times and during which activities,
Pads - usage of pads, size or change of clothing,
Ask to keep a BLADDER DIARY for min. 3 days - make sure to cover all variation of normal activities

21
Q

How to determine the severity of UI during history taking?

A

Frequency of incontinence, during what times and during which activities,
Pads - usage of pads, size or change of clothing,
Ask to keep a BLADDER DIARY for min. 3 days - make sure to cover all variation of normal activities

22
Q

What should be contained in the bladder diary?

A 
Amount, type and timing of fluid intake,
Voided volume,
Frequency of micturition,
Episodes of urgency,
Episodes of incontinence,
Activities causing leakage,
Pad & clothing changes
23
Q

UI in women - when should 2ww referral be made?

A

Suspected bladder cancer if…

Women aged 45 or over: unexplained visible haematuria w/out UTI or visible haematuria that is persistent/ recurrent after successful treatment of UTI

Women aged 60 or over: unexplained non-visible haematuria AND dysuria or raised WBC on blood test

24
Q

Which 3 specialists should you consider referring if UI is suspected without bladder cancer?

A

Urologist, urogynaecologist or nephrologist

25
Q

What are the indications for referral of SUI/ UUI patient to a urologist/ urogynaecologist or nephrologist?

A

Palpable bladder on abdominal/ bimanual examination after voiding,
Voiding difficulty,
Persistent bladder or urethral pain (refer urgently if cancer is suspected),
Associated faecal incontinence,
Suspected neurological disease,
History of previous incontinence surgery, pelvic cancer surgery or previous radiation therapy,
Recurrent UTI - for recurrent/ persistent unexplained UTI in aged 60 or older, consider non-urgent referral for bladder cancer,
Suspected urogenital fistulae

26
Q

What are the 3 main causes of SUI?

A

Prostatectomy, pregnancy & childbirth, deterioration of pelvic floor muscles/ nerves

27
Q

What are the available treatment for SUI - women?

A

Non-surgical treatments: Lifestyle changes eg. weight loss, stop smoking & modification of high/ low fluid intake,
Supervised pelvic floor exercises (continued >3mo helped 60%.) Mechanical devices eg. Contrelle Activeguard, Femsoft may help,
Bladder retraining

Pharmacological: Oestrogen therapy (topical) if atrophy present, Oral medical therapy (eg. Duloxetine - increase nerve activity that stimulates the urethral splinter to improve function) when surgery is not an option

Surgical: Occl

28
Q

What a

A
29
Q

33M. 3 hr severe right loin pain, intermittent, loin to groin radiation. N&V
Bloods: Na 138, K 3.6, Urea and creatinine normal
Urine: Blood 1+, leukocytes 1+. Nitrite -ve

What is the most appropriate investigation to confirm likely diagnosis?
Abdominal XR
CT KUB
IV urogram
Renal USS
Urine Microscopy
A

CT KUB
DDx: Renal stones

If CT unable to detect, use IV urogram
Renal USS: use in pregnant, children. Not gold-standard
Urine microscopy: if suspect infection

30
Q

60M notices increased urinary frequency, especially during the night. His stream is poor and has difficultly to start urination dribble aftrwards.
DRE: slightly enlarged prostrate with preservation of median sulcus

PSA: normal
Patient does not want surgical intervention

Most appropriate management?
Desmopressin, Finasteride, Imipramine, Oxybutynin, Tamsulosin

A

Tamsulosin
Effect: selective alpha blocker. Acts on bladder neck.
SE: postural hypotension. dry ejaculation.
Advice: don’t operate heavy machinery or drive.

Desmopression: DI, young patients with pituitary problems
Finasteride (5-alpha reductase inhibitor): shrinks prostate. 2nd line - takes 6 months and have SE (libido reduced and fatigue)
Imipramine: tricyclic antidepressant (TCA) mainly used in the treatment of depression
Oxybutynin: Treats overactive bladder. Anti-muscarinic. SE: dry eyes/mouth/ mucous membrane

31
Q

50M painless swelling in scrotim for 6 mths. Irreducible, cystic, left sided swelling which transilluminates

What is the likely diagnosis

Hydrocoele, Epididymitis, Inguinal hernia, Testicular neoplasm, Varicocoele

A

Hydrocoele
painless
cystic (fluctuates in examination)
Transillumination (transudate)

Epididymitis: red, swollen, fever and acute presentation.
When examined: painful, relieved when lifted up.

Inguinal hernia: no swelling above hernia
cough reflex

Testicular neoplasm
painless, hard and within testicle
no transillumination
firm irregular lump

Varicocoele
Bag of worms
Transillumination
more prominent on standing

32
Q

60M recurrent UTI and occasional dull ache in left groin. KUB CT shoes partial staghorn calculus in left kidney

Most common management:
Extracorporeal shock wave lithotripsy, JJ Sten and lithorotripsy, PCNL, stone dissolution therapy, ureteroscopy and extraction

A

Percutaneous nephrolithotomy (PCNL)

33
Q

Percutaneous nephrolithotomy (PCNL): Indications

LOOK UP

A

1 cm - 1.5 cm

34
Q

45M painless, hard irregular swelling of testis.
Irreducible swelling with no abnormalities of left side

What’s the likely diagnosis?
Direct/ indirect inguinal hernia, orchitis, testicular seminoma or testicular teratoma

A

Testicular seminoma
Age 45 = risk factor
more common than teratoma

Medical Conditions (8 decks)

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