Renal / Urology

Question 1

What are examples of NORMAL urine microscopy findings?

Answer 1

Urine red cells < 2 / mm^3
Urine white cells < 10 / mm^3
Squamous epithelial cells (just represent contamination from urethral / vaginal opening)
May have hyaline casts (just represent sluggish flow ie due to exercise, diuretics or dehydration)
May have crystals (in old or cold urine)

Question 2

what examples of PATHOLOGICAL urine microscopy findings and what do they suggest?

Answer 2

Red cells > 2mm^3
White cells > 10mm^3
Granular casts -> suggest chronic kidney disease
Red/white cell casts = GLOMERULAR INFLAMMATION = glomerulonephritis, pyelonephritis, interstitial nephritis.
Uric acid crystals - can support a diagnosis of renal stones

Question 3

What are the red flags warranting urgent 2-week referral for suspected bladder cancer?

Answer 3

• Age 45+ with visible haematuria in the absence of a UTI or that persists after treatment of the UTI
• Age 60+ with non-visible haematuria AND either dysuria OR a raised WCC

Question 4

Initial workup for ED?

Answer 4

Examine external genitalia 
Measure BP (HTN is the most common organic cause of ED) 
Bloods for: lipid profile, glucose + morning testosterone 

ONLY if lower urinary symptoms / mass of DRE then consider PSA.

Causes: drugs (any antihypertensives - beta blockers the worst - or any anti depressent), HTN, alcohol, MS

Question 5

Mx of UTI in child <6 months

Answer 5

If typical UTI and responds to abx -> USS within 6 weeks

iF atypical or recurrent UTI or failure to respond to treatment = DMSA (dimercapto succinic acid test) + MSUG (micturating cystourethrogram)

Question 6

Typical presentation of nephrotic syndrome?

Answer 6

heavy proteinuria (3.5g/24hrs) + hypoalbuminaemia + oedema + hypercholesterolaemia

Primary glomerular nephrotic conditions:

• Focal Segmental Glomerulosclerosis (FSGS) -> often progress to dialysis, have increasingly high BP with ^ cardiovascular risk
• Membrane nephropathy
• Minimal change nephropathy - good response to prednislone but relapse is likely

Systemic conditions that cause nephropathy:

• Diabetic glomerulosclerosis
• Amyloidosis

Question 7

Typical presentation of nephritic syndrome?

Answer 7

Haematuria + variable amount of proteinuria + oliguria / decline in renal function + ^ BP

Rapidly progressive:

• Post-infective glomerulonephritis = most commonly after a streptococcal infection -> see raised complement proteins
• Goodpasture’s (anti-GBM) -> pulmonary haemorrhage + haematuria
• Lupus nephritis (AntiDsDNA and anti nuclear positive)
• Small vessel vasculitis (ANCA positive)

Mild:

• IgA nephropathy / Berger’s -> occurs following excessive igA production in response to an URTI or gastro infection -> episodic!!
• Mesangioproliferative (associated with HIV and hepatitis infection)
• Alport syndrome (autosomal DOMINANT -> nephritic syndrome + renal failure, sensorineural deafness + retinopathies + AAA)

Question 8

what is the most common cause of nephropathy in children?

Answer 8

MINIMAL CHANGE NEPHROPATHY

Question 9

what is the most common cause of nephropathy in adults?

Answer 9

FSGS

Question 10

Potential complications of nephrotic syndrome?

Answer 10

Renal vein thrombosis (left loin pain + enlarged kidney on USS + haematuria)
Peritonitis
Reduced resistance to infection

Question 11

What is the gold standard diagnostic test to assess for urinary reflux?

Answer 11

micturating cystogram

Question 12

What is the triad of haemolytic uraemic syndrome?

Answer 12

Haemolytic anaemia
Thrombocytopenia
Acute renal failure

Occurs in children, most commonly after an E.coli GI infection

Question 13

Gold standard diagnostic test for renal artery stenosis?

Answer 13

Digital subtraction angiography

Question 14

Most common type of bladder cancer?

Answer 14

UK - transitional cell carcinoma of the bladder

Worldwide - squamous cell carcinoma of the bladder

Question 15

Mx of stress incontinence?

Answer 15

1st line = pelvic floor training
2nd line = either surgical option (mid-urethral tape, synthetic sling, intramural bulking agent) or duloxetine if surgery not appropriate

Question 16

Mx of overactive bladder / urge incontinence?

Answer 16

1st line = bladder training for at least 6 wks

2nd line -> medical Tx -> Oxybutynin (anti-muscarinic)
If oxybutynin doesn’t work -> Solifenacin, Darifenacin etc

If medical fails -> surgical -> botox injection, sacral nerve stimulation, urinary diversion

Question 17

Different types of testicular cancer?

Answer 17

> 95% are germ cell!

Germ cell tumours = seminomas and teratomas

Seminoma -> SLOWER-GROWING and affect OLDER men (late 30’s and above)
can secrete beta hCG but not AFP -> RADIOtherapy + orchidectomy

Teratomas (non-senimatous germ cell tumours) FASTER GROWING and affect YOUNGER (children and 20’s) -> secrete AFP and beta hCG -> CHEMOtherapy + orchiedectomy

Testicular Yolk sac tumours = the most common testicular tumour in children. Mainly present <2 years.

Question 18

How should male patients with lower urinary tract symptoms be managed?

Answer 18

1st - conservative -> ie pelvic floor exercises for 3 months if incontinence after prostectomy, lifestyle changes if element of overactive bladder
2nd -> medical ->

*For mod-severe LUTs symptoms = 1st line is alpha blocker [tamsulosin, doxazosin]

• If PSA >1.4 OR prostate >30g AND at a high risk of progression = 5-alpha reductase inhibitor (Finasteride / Dutasteride)
  Women should not handle! and because it gets into semen need to use a condom if pregnant or of childbearing age.

(can combine alpha blocker and finasteride if symptomatic)

Consider anticholinergic if overactive bladder

Consider late afternoon loop diuretic or desmopressin for nocturnal polyuria

Surgical Mx -> only if severe or medical failed:

1st line = TURP, TUVP (transurethral vaporisation of the prostate), HoLMEP (holmium laser enucleation of the prostate)

Only if prostate <30g -> Transurethral Incision of prostate

Only if prostate >80g -> offer prostectomy

Question 19

How should renal / ureteric stones be managed?

Answer 19

Stones <0.5cm normally pass spontaneously

For RENAL stones:
0.5cm - 2cm = ESWL (extracorporeal shockwave lithotripsy)
>2cm = percutaneous nephrolithotomy

For URETERIC stone:
If 0.5cm-1cm = ESWL
If > 1cm = ureteroscopy

Question 20

Management options for localised prostatic cancer?

Answer 20

1) Watchful waiting = for pts that do NOT have curative intent either because of old age or multiple comorbidities -> annual PSAs -> if evidence of progression then refer for hormonal therapy (LHRH agonist -> Gosarelin, Leuporelin - or LHRH antagonist -> Degarelix)

2) Active surveillance -> pts that are suitable for radical tx but don’t need the intervention yet ->
in the 1st year -> PSA every 3-4 months including PSA kinetics, DRE @ 12 months + MRI @ 12-18 months
In the 2nd year -> 6 monthly PSAs + DRE at 12 months

3) Radical treatment -> radical prostectomy, external beam radiotherapy or brachytherapy

For metastatic disease ->

• > if want to maintain their sexual function -> Bicalutamide (lower success rates + gynaecomastia)
• > if not -> bilateral orchidectomy or LHRH agonist ie Gosarelin (in the first few weeks it can cause a tumour flare which can -> spinal cord compression, urinary retention or worsening bone pain) Can use an anti-androgen (Cyproterone) alongside to reduce the risk of this.

Question 21

What is considered an abnormal PSA for each age group?

Answer 21

40-50 >2.5
50 -60 >3.5
60-70 > 4.5
70-80 > 6.5