Renal / Urology Flashcards
Benign prostatic hyperplasia (BPH) - def? Sx? Ix? Mx?
Def: slowly progressive hyperplasia of periurethral (transition) zone of prostate gland –> urinary outflow obstruction
- Common - occuring primarily in elderly men
Sx: lower urinary tract symptoms (FUND HIPS)
Ix: urinalysis (UTI), PSA (cancer) ± US/CT (abdo/pelvis)/cystoscopy
Mx:
- Acute retention = CATHETERISE
- Conservative - watchful waiting
- Medical:
- Alpha-blocker (relax sm muscle around prostatic urethra) e.g. tamsulosin
- 5-alpha-reductase inhibitor (reduce conversion of testosterone –> dihydrotestosterone - reducing androgenic stimulation of prostate) e.g. finasteride
- Surgical: TURP (transurethral resection of the prostate - shave extra prostate), open prostatectomy
- NOTE: TURP not curative - will continue to grow
Urinary tract calculi - def? presentation? Stone types? Ix? Mx? When to ADMIT/what to do if managed @home?
Def: crystal deposition within the urinary tract
Presentation: severe loin to groin pain (ureteric colic - starts around back and moves towards groin)
Stone types:
- Ca oxalate (80%)
- Mg Ammonium Phosphate (struvite) - likely staghorn calculi
- Associated with proteus mirabilis inf
- Urate
- Cysteine
Ix:
- Bedside - urine dip (microscopic haematuria)
- Bloods - U&E (post-renal AKI)
- Imaging - gold standard non-contrast CT KUB (kidneys, ureters, bladder)
- Contrast is excreted by kidneys - looking for bright white light of Ca –> if you give contrast it will mask the finding
Mx:
- Infected & obstructed = pyonephrosis –> URGENT decompression via NEPHROSTOMY (or retrograde w/ JJ stent)
- Opening between kidney & skin w/ nephrostomy bag for external collection
- Nephro (kidney) stomy (opening)
- <5mm (on CT) - allow spontaneous passing, retain stone for analysis
- >5mm (on CT):
-
Ureteroscopic lithotripsy - endoscope into ureter & using mechanical force/laser to destroy stone
- Uretero (through ureter) scopic (camera) Litho (stone) tripsy (crush)
-
Extracorporeal shockwave lithotripsy - external USS to destroy stone
- Extra (outside) corporeal (body) shockwave (USS) Lithtripsy (crushing stone)
-
Percutaneous nephrolithotomy - ONLY if stone in kidney (e.g. staghorn calculi), extract stone through skin in back
- Percutaneous (through skin) Nephro (kidney) lith (stone) otomy (cutting)
-
Ureteroscopic lithotripsy - endoscope into ureter & using mechanical force/laser to destroy stone
When to ADMIT:
- Pain not controlled
- Significantly impaired renal function
- Single kidney
- Pyrexia/sepsis
- Stone >5mm
If managed at home:
- High fluid intake + return if pain worsening/develop temperature
- OPA in 4 weeks with CT-KUB on arrival –> if stone still present need lithotripsy/nephrolithotomy
Scrotal masses - ddx?
DDx:
-
Testicular torsion - EMERGENCY & TIME-URGENT
- Elevated testis, loss of cremasteric reflex, very tender
- Tx: bilateral orchidopexy (orchidectomy - if necrotic)
-
Can you feel above swelling?
- YES - swelling separate from testis?
- YES - Epididymal cyst OR Varicocele
- NO - Tender?
- YES - Epididymo-orchitis (<35 - chalmydia, >35 - E.coli)
- NO - Hydrocele OR Tumour (raised AFP/b-hCG)
- NO - Inguinal hernia
- YES - swelling separate from testis?
Hydrocele - def? Ix?
Def: collection of fluid in tunica vaginalis
Ix: US, testicular tumour markers (AFP & bHCG - secreted by tumour, LDH - necrosis), urine culture (inf)
Causes: idiopathic, inf, trauma, tumour
Varicocele - def? What side is more common? What is it associated with x2? How can I reduce swelling?
Def: distended veins of pampiniform plexus
Key points:
- More common on left (the way left testicular vein drains into left renal vein)
- Assoc w/ infertility, renal cancer
- Swelling may reduce when lying down
Testicular cancer - Epidemiology & mets? Ix? Mx?
Epidemiology & mets:
* Mets to para-aortic LNs
* Most common malignancy in males 20-40yrs
PC: painless mass (30% painful), dragging sensation
Ix:
* Blood testicular tumour markers: alpha-fetoprotein, beta-hCG, LDH (necrosis, others secreted by tumour itself)
* Testicular US –> CT-CAP for staging (would likely do orchidectomy before CT)
* Urine dip (look for infection) –> culture
Mx:
* Orchidectomy – take inguinal approach (scrotal approach risks mets and inguinal is coming out the same way the testicle drops) - only time would not do this first is when respiratory compromise then would do chemo first
* BEP chemotherapy follow-up = very good response typically
* Very good prognosis - good/intermediate prognosis groups have >90% 5-yr survival
Bladder cancer - presentation? Ix? Mx?
Most common = transitional cell carcinoma (urothelial)
Presentation:
- Painless visible haematuria (or asymptomatic non-visible haematuria)
- Irrigative LUTS (urgency, suprapubic pain)
- Recurrent UTIs
- Pain, weight loss, lymphoedema
Ix:
- Initial:
- Urine dip (blood, leucocytes)
- MC&S (use MSU - RBCs & WBCs, no bacterial growth)
- Bloods - FBC
- Flexible cystoscopy (lower urinary tract) + CT-urogram (upper urinary track if visible haematuria –> if non-visible low-risk use US)
- Dx & staging = Transurethral Bladder Tumour Resection (TURBT) - resects full tumour + histology
- Intravesical therapy:
- Bacillus Calmette-Guerin (BCG) instilled into bladder –> reduces superficial bladder cancer recurrence (causes immune response to remaining tumour cells, same substance as in BCG vaccine)
- Mitomycin - cytotoxic chemo agent
- Intravesical therapy:
Mx: 2wk wait urology
- Muscle invasive = cystectomy (young people) or radiotherapy/chemotherapy (older)
- Superficial = surveillance cystoscopies, intravesical chemo
- Mets = systemic therapy
AD Polycystic Kidney Disease (ADPKD)
Presentation? Associations? Screening?
ADPKD - Most freq genetic cause of renal failure in adults (abn chr 16)
* Cysts in kidneys and other organs (liver/pancreas/spleen)
* Associations - hepatic cysts, berry aneurysms (risk of ICH), mitral valve prolapse
* PC: haematuria (cyst rupture), flank pain (growing cyst), HTN (cysts prod renin), FHx - ICH
* Imaging including family screening - renal USS
* Tx: supportive
Testicular torsion - presentation? Tx?
Presentation: sudden-onset pain, high fixed position, absent cremasteric reflex
Tx: bilateral orchidopexy (both sides as increased risk of torsion in the other side)
What is paraphimosis? Causes? Pathophysiology? Mx?
Paraphimosis def: unable to pull back the foreskin
Causes: tight foreskin (phimosis), a complication of urinary catheter (always remember to replace foreskin after withdrawing for catheter insertion)
Pathophysiology: constrictive effect of foreskin –> oedema of distal penis –> ischaemia/necrosis (if severe)
Mx: UROLOGICAL EMERGENCY - must be reduced ASAP
- Reduce with - Lubricating jelly OR dextrose-soaked gauze
- If difficult - needle used to make small holes in penis –> drainage of oedema
Prostate cancer - Ix? Mx?
Ix:
- PR exam, PSA
- FBC, U&E, LFTs
- Transrectal ultrasound (TRUS)-guided needle biopsy
- Gleason score = PC grading
- TNM staging
- Multiparametric MRI
Mx: surgery/radiotherapy
- Radial prostatectomy ± LN dissection
- External beam radiotherapy/brachytherapy
- Androgen-deprivation therapy (ADT)
Urinary incontinence - types & Tx?
Stress incontinence (leak on laugh/cough):
- Pelvic muscle exercises
- Pseudoephedrine (2nd - Duloxetine)
- Retropubic suspension/colposuspension
Urge incontinence (preceded by the urge to pass urine):
- Bladder retraining
- Anticholinergic e.g. Oxybutynin (not if >80yrs), Tolterodine
Overactive bladder syndrome (urge but not incontinence - increased freq + nocturia): same as urge incontinence
Glomerular disease - nephrotic vs nephritic syndrome
Nephritic syndromes - blood/protein loss
Post-streptococcal glomerulonephritis
*** 2wks after streptococcal tonsilitis **(GAS)/skin infection
* Presentation: oedema, HTN, macroscopic haematuria, proteinuria
* Ix: low C3 lvls, high ASOT
* Mx: BP control
IgA nephropathy (Berger’s disease)
* PC: 24-48hrs after URTI/GI infection -> visible haematuria + flank pain
Granulomatosis with polyangitis (Wegener’s granulomatosis)
* Systemic vasculitis of small/medium vessels
* Triad: upper & lower resp involvement + glomerulonephritis +/ cutaneous/ocular/MSK/PNS
Eosinophilic granulomatosis with polyangitis (Churg-Strauss syndrome)
* Vasculitis + Asthma + Eosinophilia +/- GI/cardiac involvement
* Ix: p-ANCA (perinuclear anti-neutrophil cytoplasmic Abs)
Alport’s syndrome - X-linked hereditary (type IV collagen, mainly affects boys)
* Glomerulonephritis (intermittent visible haematuria in infancy) + SN hearing loss +/- eye abn
Anti-glomerular basement membrane ab disease (Goodpasture’s disease)
* Triad: glomerulonephritis, pul haemorrhage, anti-GDM ab formation
Nephrotic syndrome - urinary protein loss >3.5g/day, low albumin, oedema
Minimal change disease (most common nephrotic in kids)
* SBAs: swollen eyes/testes, 3+ protein on urine dip
* Features: proteinuria, oedema (periorbital/scrotal), low albumin (<30), high lipids, thrombophilia
* Ix: renal biopsy - electron microscopy = fusion of epithelial podocytes “minimal change as such minimal change in pathology”
* Mx: CS (pred)
Focal segmental glomerulosclerosis (most common nephrotic in adults)
* Caused by podocyte injury in glomeruli
* Can be primary (idiopathic) or secondary to HIV/obesity/meds
Membranous nephropathy (common nephrotic in adults)
* Mx: low-risk - conservative, high-risk - CS + cytotoxic/cyclosporin
Diabetic nephropathy - often aSx - foamy urine
AL amyloidosis - extracellular deposition of insoluble abn proteins (commonly AA), kidneys most commonly affected
* PC: very variable - WL, fatigue, oedema (resistant to diuretics)
* Ix: congo red staining + polarised light -> green fluorescence
* Mx: chemo/stem cell reconstitution
Hallmark feature of genitourinary TB?
Sterile pyuria
Normally presents as repeated UTIs resistant to typical abx
UTI Dx & management
Pyelonephritis Mx
If female + uncomplicated <65yrs/uncatheterised -> urine dip:
* +ve nitrites/leuk + RBC -> UTI likely
* +ve leuk, -ve nitrites -> UTI possible
* If all -ve UTI unlikely
If male do not use urine dip to dx (if not catheterised/>65yrs/indwelling catheter) and don’t start abx until urine culture confirms Dx
Mx: nitrofurantoin 3d (if eGFR ≥45, C/I: G6PD def/acute porphyria), 2nd - trimethoprim 3d (eGFR 15-30 use half dose after 3 days, <15 - use half dose)
* 7d tx in men, use nitro if pregnant (except at term)
Pyelonephritis (E. coli/Kleb) Mx: Cefalexin 7-10d
Renal artery stenosis overview
RAS - narrowing of renal artery lumen (sign if ≥50% reduction) due to atherosclerosis/fibromuscular dysplasia -> ↓ renal blood flow -> ↓ renal function -> ischaemic nephropathy & HTN (high renin/ANG-II)
* PC: asymptomatic - uncontrollable HTN, worsening eGFR (esp after starting ACEi), recurrent flash pul oedema
* Ix: Dx via imaging
* Mx: HTN-meds, aspirin + statins +/- angioplasty & stenting ONLY if HTN despite aggressive meds/rapidly declining eGFR/recurrent flash pul oedema
Fanconi syndrome summary
Fanconi syndrome - inh/acquired disturbance of renal tubular transport -> aminoaciduria, glycosuria, phosphaturia, renal tubular acidosiis T2 (proximal)
* PC: polyuria, polydipsia, bouts of dehydration +/- fever, bone deformities (Ricket’s in kids, ostemalacia in adults)
* Mx: replacing lost substances + TX cause
