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Renal & Urology Flashcards

1
Q

What is nephrotic syndrome?

A

Triad:

  1. Proteinuria (>3.5 g/24 hours)
  2. Hypoalbuminaemia (<30 g/L)
  3. Peripheral oedema

Hypercholesterolaemia also a common feature

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2
Q

What are the causes of nephrotic syndrome?

A

Most commonly caused by minimal change glomerulonephritis in children

However, all forms of glomerulonephritis can cause it

Other causes:
DM
SCD
Amyloidosis
Malignancy - lung and GI adenocarcinomas
Drugs - NSAIDs
Alport's syndrome
HIV
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3
Q

What are the risk factors for nephrotic syndrome?

A
  1. Medical conditions that can damage your kidneys - DM, lupus, amyloidosis
  2. Drugs - NSAIDs, drugs used to fight infections
  3. Certain infections - HIV, hep B, hep C, malaria
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4
Q

Summarise the epidemiology of nephrotic syndrome

A

Usually adults

M:F = 2:1

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5
Q

What are the presenting symptoms of nephrotic syndrome?

A

FHx of atopy
FHx of renal disease
Swelling of face, abdo, limbs, genitalia (due to hypoAlb)
Weight gain - due to excessive fluid retention
Fatigue
Foamy urine
Loss of appetite

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6
Q

What are the signs of nephrotic syndrome?

A

Oedema: periorbital, peripheral, genital

Ascites: fluid thrill, shifting dullness

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7
Q

How is nephrotic syndrome investigated?

A

Urinanalysis - ++++ proteinuria > 3.5g over 24h
- protein looks frothy

Bloods - hypoalbuminaemia + hyperlipidaemia

Tests to identify cause:

  • SLE: ANA, anti-dsDNA antibodies
  • Infections: ASO titre for group A B-haemolytic streptococcal infection; HBV serology; Plasmodium malariae blood film
  • Goodpasture’s syndrome: anti-glomerular basement antibodies
  • vasculitides - polyangiitis w granulomatosis, microscopic polyarteritis (check ANCA)

Renal US
Renal biopsy

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8
Q

What is AKI?

A

An abrupt loss of kidney function resulting in the retention of urea and other nitrogenous waste products and the dysregulation of extracellular volume and electrolytes

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9
Q

Explain the aetiology of AKI

A

May be multifactorial

  1. Pre-renal:
    - Decreased vascular volume: haemorrhage, D+V, burns, pancreatitis
    - Decreased CO: cardiogenic shock, MI
    - Systemic vasodilation: sepsis, drugs
    - Renal vasoconstriction: NSAIDs, ACE-i, ARB, hepatorenal syndrome
  2. Renal:
    - Glomerular: glomerulonephritis, acute tubular necrosis
    - Interstitial: drug reaction, infection, infiltration (eg sarcoid)
    - Vessels: vasculitis, HUS, TTP, DIC
  3. Post-renal:
    - Within renal tract: stone, renal tract malignancy, stricture, clot
    - Extrinsic compression: pelvic malignancy, prostatic hypertrophy, retroperitoneal fibrosis
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10
Q

What are the risk factors for AKI

A

Pre-existing CKD
Age
Male
Comorbidity - DM, CVD, malignancy, chronic liver disease, complex surgery

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11
Q

What are the presenting symptoms of AKI?

A

Depends on underlying cause

  • Oliguria/anuria (abrupt anuria suggests post-renal obstruction)
  • N+V
  • Dehydration
  • Confusion
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12
Q

What are the signs of AKI O/E?

A
  • Hypertension
  • Distended bladder
  • Dehydration
  • Postural hypotension
  • Fluid overload (in HF, cirrhosis, nephrotic syndrome)
  • Raised JVP
  • Pulmonary and peripheral oedema
  • Pallor, rash, bruising (vascular disease)
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13
Q

How is AKI investigated?

A
  1. Urinanalysis
    - Blood - suggests nephritic cause
    - Leucocyte esterase and nitrites - UTI
    - Glucose
    - Protein
    - Urine osmolality
  2. Bloods
    FBC, film, U+Es, clotting, CRP, virology (hepatitis, HIV)
  3. Immunology
    - Serum Igs + protein electrophoresis for multiple myeloma - also look for Bence-Jones proteins in urine
    - ANA, anti-dsDNA abs (active lupus) - SLE
    - Low omplement levels - active lupus
    - Anti-GBM antibodies - Goodpasture’s syndrome
    - Antistreptolysin-O antibodies - high after Streptococcal infection
  4. Ultrasound
    - Check for post-renal cause
    - Look for hydronephrosis
  5. Other imaging
    - CXR: pulm oedema
    - AXR: renal stones
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14
Q

How is AKI managed?

A

Treat the cause

4 main components:

  1. Protect patient from hyperkalaemia (calcium gluconate)
  2. Optimise fluid balance
  3. Stop nephrotoxic drugs
  4. Consider for dialysis
  • Monitor serum Cr, Na, K, Ca, phosphate, glucose
  • Identify and treat infection
  • Urgent relief of urinary tract obstruction
  • Refer to nephrology if intrinsic renal disease suspected
  • Renal replacement therapy (RRT) if:
  • HyperK/pulm oedema refractory to medical Mx
  • Severe metabolic acidaemia
  • Uraemic complications
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15
Q

What are the possible complications of AKI?

A 
Pulmonary oedema
Acidaemia
Uraemia
Hyperkalaemia
Bleeding
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16
Q

What are the indicators for poor prognosis of AKI?

A

Inpatient mortality varies depending on cause and comorbidities

Age
Multiple organ failure
Oliguria
Hypotension
CKD
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17
Q

What are the most common causes of AKI

A
  1. Sepsis
  2. Major surgery
  3. Cardiogenic shock
  4. Other hypovolaemia
  5. Drugs
  6. Hepatorenal syndrome
  7. Obstruction
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18
Q

What is the in the KDIGO classification of AKI?

A

Rise in creatinine > 26 micromol/L within 48h
Rise in creatinine > 1.5 x baseline (ie before AKI) within 7 days
Urine output <0.5mL/kg/h for >6 consecutive hours

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19
Q

What is the in the KDIGO classification of AKI?

A

Rise in creatinine > 26 micromol/L within 48h
Rise in creatinine > 1.5 x baseline (ie before AKI) within 7 days
Urine output <0.5mL/kg/h for >6 consecutive hours

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20
Q

What is amyloidosis?

A

A group of disorders characterised by extracellular deposits of a protein in abnormal fibrillar form, resistant to degradation

AL - primary
AA - secondary
Familial

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21
Q

Summarise the epidemiology of amyloidosis

A

UK:

  • age-adjusted incidence = 5.1-12.8/million/yr
  • 60 new cases annually
  • Higher in males
  • Mean age of diagnosis = 63
  • Higher in Blacks, lower in Asians
  • AA = 10% of systemic amyloidosis
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22
Q

What are the risk factors for amyloidosis?

A
  1. Monoclonal gammopathy of undetermined significance (MGUS)
  2. Inflammatory polyarthropathy - most common AA cause
  3. Chronic infections –> AA
  4. IBD (Crohn’s esp.) –> AA
  5. Familial periodic fever syndromes –> AA

(6. Castleman’s disease - non-cancerous tumours of lymphoid tissue - plasma cell variant –> AA)

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23
Q

What are the presenting symptoms of amyloidosis?

A

Fatigue
Extreme weight loss
Dyspnoea on exertion

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24
Q

What are the signs of amyloidosis O/E?

A
  • Raised JVP
  • Lower extremity peripheral oedema (due to hypoalbuminaemia from nephrotic syndrome)

Less so:

  • Periorbital purpura (highly specific)
  • Macroglossia (highly specific for AL primary)
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25
Q

How is amyloidosis investigated?

A
  1. Serum immunofixation
    - positive for monoclonal protein in 60% of patients w immunoglobulin light chain amyloidosis
  2. Urine immunofixation
    - positive for monoclonal protein in 80% of patients w AL
    - presence of light chain protein suggestive of multiple myeloma and amyloidosis
  3. Immunoglobulin free light chain assay
    - abnormal kappa:lambda
    - extremely high sensitivity, >95%, for diagnosing AL
  4. Bone marrow biopsy
    - clonal plasma cells
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26
Q

How is amyloidosis investigated?

A
  1. Serum immunofixation
    - positive for monoclonal protein in 60% of patients w immunoglobulin light chain amyloidosis
  2. Urine immunofixation
    - positive for monoclonal protein in 80% of patients w AL
    - presence of light chain protein suggestive of multiple myeloma and amyloidosis
  3. Immunoglobulin free light chain assay
    - abnormal kappa:lambda
    - extremely high sensitivity, >95%, for diagnosing AL
  4. Bone marrow biopsy
    - clonal plasma cells
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27
Q

What is benign prostatic hyperplasia?

A

Slowly progressive nodular hyperplasia of the periurethral (transitional) zone of the prostate gland

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28
Q

Summarise the epidemiology of benign prostatic hyperplasia

A

Common

70% of men > 70 yrs have histological BPH
50% of them experience symptoms

More common in West
More common in Afro-Caribbeans

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29
Q

What is the aetiology of benign prostatic hyperplasia?

A

UNKNOWN

Link with hormonal changed (androgens)

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30
Q

What are the risk factors for benign prostatic hyperplasia?

A
  • Over 50
  • FHx
  • Non-Asian
  • Smoking
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31
Q

What are the presenting symptoms of benign prostatic hyperplasia?

A 
FUND HIPS - storage and voiding symptoms:
Frequency
Urgency
Nocturia
Dysuria/dribbling
Hesitancy
Incomplete voiding
Poor stream
Smell/odour

Acute retention symptoms:

  • Sudden inability to pass urine
  • Severe pain

Chronic retention symptoms:

  • Painless
  • Frequency - passage of small volumes
  • Nocturia
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32
Q

What are the signs of benign prostatic hyperplasia O/E?

A

DRE: smoothly enlarged prostate w palpable midline groove

Signs of acute retention:
Suprapubic pain
Distended, palpable bladder

Signs of chronic retention:
Large distended painless bladder (vol > 1L)
Signs of renal failure

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33
Q

How is benign prostatic hyperplasia investigated?

A
  1. Urinanalysis - pyuria (white cells or pus) - complicated UTI
  2. Bloods
    PSA - elevated - underlying prostate Ca or prostatitis
    U+Es - impaired renal function
  3. Midstream urine - MC&S
  4. International Prostate Symptom Score
  5. Global bother score
  6. Volume charting
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34
Q

How is benign prostatic hyperplasia managed?

A

In emergency (acute urinary retention): catheterisation

Conservative (if mild): watchful waiting

Medical:

  • selective alpha blocker (tamsulosin) relax smooth muscle of internal sphincter and prostate capsule
  • 5a-reductase inhibitors (finasteride) inhibit conversion of testosterone to DHT, can reduce prostate size by 20%

Surgery:
TURP
Open prostatectomy

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35
Q

What are the possible complications of benign prostatic hyperplasia?

A 
Recurrent UTI
Acute or chronic urinary retention
Urinary stasis
Bladder diverticula
Stone development
Obstructive renal failure
Post-obstructive diuresis
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36
Q

What is the prognosis of benign prostatic hyperplasia?

A
  • Mild symptoms usually well controlled medically

- Most patients get significant relief from surgery

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37
Q

What is TURP?

A

Transurethral resection of prostate

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38
Q

What are the indications for TURP?

A

BPH

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39
Q

What are the possible complications of TURP?

A
  • Retrograde ejaculation (up into bladder bc internal sphincter is relaxed)
  • Haemorrhage
  • Incontinence
  • TURP syndrome: seizures or CV collapse due to hypervolaemia and hypoNa due to absorption of glycine irrigation fluid)
  • Urinary infection
  • Erectile dysfunction
  • Urethral stricture
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40
Q

What are epididymitis and orchitis?

A

Inflammation of the epididymis or testes

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41
Q

Summarise the epidemiology of epididymitis and orchitis

A

Common
Affects all age groups
Most common 20-30yo

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42
Q

What are the aetiologies of epididymitis and orchitis?

A

Most cases are INFECTIVE in origin

Bacterial:
If <35: Chlamydia, Gonococcus
If >35: mainly coliforms (Enterobacter, Klebsiella)
Rare: TB, syphilis

Viral: mumps

Fungal: Candida if immunocompromised

1/3 are idiopathic

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43
Q

What are the risk factors for epididymitis and orchitis?

A

Diabetes

Rare: vasculitis (eg Henoch-Scholein purpura)

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44
Q

What are the presenting symptoms of epididymitis and orchitis?

A
  • Painful, swollen and tender testis or epididymis

- Penile discharge

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45
Q

What are the signs of epididymitis and orchitis O/E?

A
  • Swollen and tender epididymis or testis
  • Scrotum may be erythematous and oedematous
  • Pyrexia
  • Painful walking
  • Eliciting cremasteric reflex may be painful
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46
Q

How are epididymitis and orchitis investigated?

A
  1. Urine: dipstick + early morning for Mc&S
  2. Bloods:
    FBC - high WCC
    High CRP
    U+Es
  3. Imaging: increased blood flow on duplex examination
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47
Q

How are epididymitis and orchitis managed?

A

Medical: ABx

Surgical:

  • exploration of testicles if testicular torsion cannot be excluded clinically
  • required if abscess develops
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48
Q

What are the possible complications of epididymitis and orchitis?

A
  • Pain
  • Abscess
  • Fournier’s gangrene (if infection left untreated and spreads)
  • Mumps orchitis could cause testicular atrophy and fertility issues
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49
Q

What are the prognoses of epididymitis and orchitis?

A

Good if treated

May take up to 2 months for swelling to resolve

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50
Q

How does the onset of epididymitis or orchitis differ from that of testicular torsion?

A

Less acute onset

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51
Q

What is chronic kidney disease?

A

Progressive loss of kidney function over a period of months or years

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52
Q

Summarise the epidemiology of CKD

A

Common
Risk increases with age
Often associated with other diseases, eg CVD

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53
Q

What is the aetiology of CKD?

A

Most common cause in adults = diabetes (1/3 develop KD within 5-10yrs of diagnosis)

HTN = 2nd most common cause

Less common causes = 
polycystic kidney disease
obstructive uropathy
glomerular nephrotic and nephritic syndromes
membranous nephropathy
lupus nephritis
amyloidosis
rapidly progressive glomerulonephritis
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54
Q

What are the risk factors for CKD?

A

DM
HTN
>50
Childhood kidney disease

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55
Q

What are the presenting symptoms of CKD?

A

Often asymptomatic
May be incidental finding of routine blood/urine test

Anorexia
N+V
Fatigue
Pruritus
Peripheral oedema
Muscle cramps
Sexual dysfunction
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56
Q

What are the signs of CKD O/E?

A

May show signs of underlying disease (eg SLE)
May show complications of CKD (eg anaemia)

Skin pigmentation
Excoriation marks
Pallor
HTN
Peripheral + pulmonary oedema
Peripheral vascular disease
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57
Q

How is CKD investigated?

A
  1. Assessment of renal function: urea, creatinine, isotopic GFR (gold standard)
  2. Biochemistry:
    - glucose: check for undiagnosed DM and diabetic control
    - raised K
    - also check Na, HCO3, Ca, PO4
  3. Serology:
    - antibodies: ANA for SLE< c-ANCA for Wegener’s, anti-GBM for Goodpasture’s
    - hepatitis serology
    - HIV serology
  4. Urinanalysis:
    - check for proteinuria/haematuria
    - 24h urine collection
    - serum or urine protein electrophoresis - check for multiple myeloma
  5. Imaging:
    - US to check for structural abnormalities
    - CT/MRI
    - XR KUB - check for stones
  6. Renal biopsy
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58
Q

What is a limitation of using creatinine to assess renal function?

A

Renal function can drop considerably with minimal change in serum creatinine

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59
Q

Why is looking at serum urea not ideal to assess renal function

A

Varies massively depending on hydration status and diet

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60
Q

What is glomerulonephritis?

A

An immunologically mediated inflammation of the renal glomeruli

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61
Q

Summarise the epidemiology of glomerulonephritis

A

Accounts for 25% of cases of chronic renal failure

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62
Q

What is the aetiology of glomerulonephritis?

A

Can result from renal-limited glomerulopathy or from glomerulopathy-complicating systemic disease, eg SLE, vasculitis

  1. Glomerular injury caused by inflammation due to leukocyte infiltration, ab deposition, complement activation
  2. Idiopathic
  3. Infection
  4. Systemic inflammatory conditions: vasculitides (SLE, RA< anti-GBM disease, granulomatosis)
  5. Drugs: penicillamine, gold sodium thiomalate, NSAIDs, captopril, heroin, mitomycin C, cocaine, anaoblic steroids)
  6. Metabolic disorders: DM, HTN, thyroiditis
  7. Malignancy: lung, colorectal Ca, melanoma, Hodgkin’s lymphoma
  8. Hereditary disorders: Fabry’s disease, Alport’s syndrome, thin basement membrane disease
  9. Deposition diseases: amyloidosis, light chain deposition disease
63
Q

What are the risk factors for glomerulonephritis?

A 
Group A beta-haemolytic Streptococcus
Respiratory infections
GI infections
HBV, HCV, HIV
Infective endocarditis
SLE
Systemic vasculitis
Cancer: Lymphoma
Lung Ca
Colorectal Ca
64
Q

What are the presenting symptoms of glomerulonephritis?

A 
Haematuria
Swelling
Polyuria/oliguria
History of recent infection
Generalised vasculitic picture: anorexia, nausea, malaise, skin rash, arthralgia,
Weight loss
Fever
Haemoptysis
Abdo pain
Sore throat
65
Q

What are the signs of glomerulonephritis O/E?

A 
HTN
Generalised oedema
Anorexia
Skin rash
Fever
Abdo guarding
66
Q

How is glomerulonephritis investigated?

A
  1. Bloods: FBC, U+Es, Cr, LFTs (check albumin), lipid profile, complement studies, antibodies - ANA, anti-dsDNA, ANCA, anti-GBM, cryoglobulins
  2. Urine:
    - MC&S for red cell casts
    - 24h collection: Cr clearance and protein
  3. Imaging: renal tract US to exclude other pathology (eg obstruction)
  4. Renal biopsy for microscopy
  5. Investigations for associated conditions: eg HBC, HCV, HIV serology
67
Q

What is hydrocele?

A

The excessive collection of serous fluid within the tunica vaginalis

68
Q

Summarise the epidemiology of hydrocele

A

Very common in children in first year of life

Common in older men

69
Q

What is the aetiology of hydrocele?

A
  • Congenital
  • Idiopathic
  • Tumour
  • Infection
  • Trauma
  • Underlying testicular torsion
  • Testicular appendage
70
Q

What are the risk factors for hydrocele?

A
  • Indirect inguinal hernias in children
  • Epididymo-orchitis
  • Filariasis (in countries of high prevalence)
71
Q

What are the presenting symptoms of hydrocele?

A

Scrotal swelling
Usually asymptomatic
May complain of pain or urinary symptoms due to underlying cause

72
Q

What are the signs of hydrocele O/E?

A

Scrotal swelling
Possible to get above swelling
Transilluminates
Difficult to separate swelling from testicle

73
Q

How is hydrocele investigated?

A
  1. US - exclude tumour
  2. Urine - dipstick and MSU for infection
  3. Bloods - markers of testicular tumours = a-fetoprotein, B-HCG, LDH
74
Q

What is polycystic kidney disease?

A

Autosomal dominant inherited disorder characterised by the development of multiple renal cysts that gradually expand and replace normal kidney substance, variably associated with extrarenal (liver and CV) abnormalities

75
Q

Summarise the epidemiology of polycystic kidney disease

A

Most common inherited kidney disorder

Responsible for 10% of end-stage renal failure

Presents at 30-40yrs

20% have no FHx

76
Q

What is the aetiology of polycystic kidney disease?

A
  • 85% caused by mutations in PKD1 on Chr 16
  • Membrane-bound multidomain protein involved in cell-cell and cell-matrix interactions
  • 15% caused by mutations of PKD2 on Chr 4
77
Q

What are the risk factors for polycystic kidney disease?

A

FHx of autosomal-dominant PKD

FHx of cerebrovascular event

78
Q

What are the presenting symptoms of polycystic kidney disease?

A

May be asymptomatic
Flank pain - may result from cyst enlargement/bleeding, stone, blood clot migration, infection

Haematuria
HTN
Associated w berry aneurysms and may present with SAH

79
Q

What are the signs of polycystic kidney disease O/E?

A 
Abdo distension
Enlarged cystic kidneys
Palpable liver
HTN
Signs of chronic renal failure
Signs of associated AAA or aortic valve disease
80
Q

How is polycystic kidney disease investigated?

A

US or CT:

  • multiple cysts bilaterally in enlarged kidneys
  • liver cysts may be seen
81
Q

What is renal artery stenosis?

A

Stenosis of the renal artery

82
Q

Summarise the epidemiology of renal artery stenosis

A

Accounts for 1-5% of HTN

90% of RAS = atherosclerotic RAS

Fibromuscular dysplasia = 10% of RAS

Females 2-10x more likely to have FMD - onset before 30

83
Q

What is the aetiology of renal artery stenosis?

A

Atherosclerosis (older patients) - widespread aortic disease involving the renal artery ostia

Fibromuscular dysplasia (younger patients):

  • unknown aetiology
  • may be associated w collagen disorders, neurofibromatosis, Takayasu’s arteritis
  • may be associated w micro-aneurysms in mid and distal renal arteries
84
Q

What are the risk factors for renal artery stenosis?

A

Dyslipidaemia
Smoking
DM
Female

85
Q

What are the presenting symptoms of renal artery stenosis?

A

Hx of HTN < 50
HTN refractory to Tx
Accelerated HTN and renal deterioration on starting ACE-i
Hx of flash pulmonary oedema

86
Q

What are the signs of renal artery stenosis O/E?

A

HTN
Signs of renal failure in advanced bilateral disease
Renal artery bruits

87
Q

How is renal artery stenosis investigated?

A
  1. Duplex US
  2. US measurement of kidney size
  3. CT angiogram or MR angiography - risk of contrast nephrotoxicity
  4. Digital subtraction angiography = gold standard
  5. Renal scintigraphy
88
Q

What is testicular torsion?

A

Twisting or torsion of the spermatic cord results, initially, in venous outflow obstruction from the testicle, progressing to arterial occlusion and testicular infarction if not correct

A surgical emergency

89
Q

Summarise the epidemiology of testicular torsion

A

Most common cause of acute scrotal pain in 10-18yo

90
Q

What is the aetiology of testicular torsion?

A

Intravaginal (most common):
Spermatic cord twists within the tunica vaginalis

Extravaginal (usually in neonates)
Entire testis and tunica vaginalis twist in vertical axis on spermatic cord
Due to incomplete fixation of gubernaculum to scrotal wall allowing free rotation

91
Q

What are the risk factors for testicular torsion?

A

Imperfectly descended testes

High investment of tunica vaginalis

92
Q

What are the presenting symptoms of testicular torsion?

A

Sudden onset severe hemiscrotal pain
Abdo pain
N+V

93
Q

What are the signs of testicular torsion O/E?

A
  • Swollen, erythematous scrotum on affected side
  • Swollen testicle will lie slightly higher
  • Testicle may lie horizontal
  • Thickened cord
  • Testicular appendix - visible necrotic lesion on transillumination
94
Q

How is testicular torsion investigated?

A

Dopper/duplex imaging

  • do NOT delay surgery
  • arterial inflow reduced in testicular torsion vs increased in epididymo-orchitis
95
Q

How is testicular torsion managed?

A
  • Exploration of scrotum within 6h of onset of symptoms
  • After testicle twisted back into place, bilateral orchidopexy performed
  • Suture testicle to scrotal tissue to prevent recurrence
  • If testicle, orchidectomy performed
96
Q

What are the possible complications of testicular torsion?

A

Testicular infarction
Testicular atrophy
Infection
Impaired fertility (due to production of anti-sperm antibodies)

97
Q

What is the prognosis of testicular torsion?

A

From onset, testicle may only survive 4-6 hours

With prompt surgical intervention, most testicles are salvaged

98
Q

What are urinary tract calculi?

A

Crystal deposition within the urinary tract

AKA nephrolithiasis

99
Q

Summarise the epidemiology of urinary tract calculi?

A 
Common
2-3% of general population
3x more common in males
20-50yos
Bladder stones more common in developing countries
100
Q

What is the aetiology of urinary tract calculi?

A

Many cases are idiopathic

Metabolic causes:
HyperCa
Hyperuricaemia
Hypercystinuria
Hyperoxaluria

Infection: hyperuricaemia

Drugs: indinavir

101
Q

What are the risk factors for urinary tract calculi?

A

Low fluid intake

Structural urinary tract abnormalities (eg horseshoe kidney)

102
Q

What are the presenting symptoms of urinary tract calculi?

A 
Often asymptomatic
Severe loin to groin pain
N+V
Urinary urgency, frequency, retention
Haematuria
103
Q

What are the signs of urinary tract calculi O/E?

A

Loin to lower abdo tenderness
No signs of peritonism
Leaking AAA = main differential in older men
Signs of systemic sepsis if there is an obstruction and infection above the stone

104
Q

How are urinary tract calculi investigated?

A
  1. BLOODS
    - FBC - high WCC if infection
    - U+Es - check renal function
    - Ca, urate, phosphate
  2. URINE
    - Dipstick - haematuria
    - MC&S - infection
  3. IMAGING
    - XR KUB - radio-opaque kidney stones
    - IV urography - visualisation of kidneys and ureters
    - US - may show hydronephrosis and hydroureter
    - Non-enhanced spiral CT - image stones
    - Isotope radiography - assess kidney function
105
Q

How are urinary tract calculi managed?

A

Acute:

  • analgesia
  • bed rest
  • fluid replacement
  • urine collection to try and retrieve any passed stone

Obstructed, infected kidney = emergency - relieve obstruction

Removal of calculi:

  • Urethroscopy +- JJ stent
  • Extracoporeal Shock-Wave Lithotripsy (ESWL)
  • Percutaneous Nephrolithotomy (PCNL)

Treatment of cause:

  • parathyroidectomy if hyperCa due to hyperPT
  • allopurinol if hyperuricaemia

Advice:
- increase oral fluid intake

106
Q

What are the possible complications of urinary tract calculi?

A

Infection (pyelonephritis)
Septicaemia
Urinary retention

107
Q

What is the prognosis of urinary tract calculi?

A

Good
However infection of calculus could lead to irreversible renal scarring
Recurrence of 50% over 5 years

108
Q

Where are bladder stones more common?

A

In developing countries

109
Q

Where are upper UT stones more common?

A

In industrialised countries

110
Q

What is a UTI?

A

The presence of a pure growth of > 10^5 organisms per mL of fresh MSU (lab - not necessity)

111
Q

How can UTIs be classified?

A

Lower UTI - affecting urethera (urethritis), bladder (cystitis) or prostate (prostatitis)

Upper UTI - affecting renal pelvis (pyelonephritis)

Uncomplicated UTI - normal renal tract and function

Complicated UTI - abnormal renal/genitourinary tract, voiding difficulty/obstruction, reduced renal function, impaired host defences, virulent organism (eg S. aureus)

112
Q

What is the aetiology of UTI?

A 
Most caused by Escherichia Coli
Also:
- Staphylococcus saprophyticus
- Proteus mirabilis
- Enterococci
113
Q

What are the risk factors for UTI?

A 
Female
Sexual intercourse
Exposure to spermicide
Pregnancy
Menopause
Immunosuppression
Catheterisation
Urinary tract obstruction
Urinary tract malformation
114
Q

What are the presenting symptoms of UTI?

A

Cystitis:

  • frequency
  • urgency
  • dysuria
  • haematuria
  • suprapubic pain

Prostatis:

  • flu-like symptoms
  • low backache
  • few urinary symptoms
  • swollen or tender prostate on PR

Acute pyelonephritis:

  • high fever
  • rigors
  • vomiting
  • loin pain and tenderness
  • oliguria (if AKI)
115
Q

What are the signs of UTI O/E?

A 
Fever
Abdo or loin tenderness
Foul-smelling urine
Distended bladder (occasionally)
Enlarged prostate (if prostatits)
116
Q

How is UTI investigated?

A

Urine dipstick - positive leukocyte esterase and nitrites

Urine microscopy - leukocytes if infection

Urine culture - exclude diagnosis or if patient failed to respond to empirical abx

US - rule out obstruction

Bloods - FBC, U+Es, CRP, cultures if systemically unwell and risk of urosepsis

117
Q

How is UTI managed?

A

Uncomplicated:
Trimethoprim or nitrofurantoin
3-6 days
Men may need longer course

Alternatives:
Co-amoxiclav or cefalexin

118
Q

What are the possible complications of UTI?

A 
Ascending infection can lead to:
Pyelonephritis
Perinephric and intrarenal abscess
Hydronephrosis or pyonephrosis
AKI
Sepsis

Prostatic involvement (eg prostatitis) in men is common

119
Q

What is the prognosis of UTI?

A

Good w appropriate treatment

120
Q

What atypical organisms can cause UTI?

A

Usually in immunocompromised individuals

Klebsiella
Candida albicans
Pseudomonas aeruginosa

121
Q

What is varicocoele?

A

Dilated veins of the pampiniform plexus forming a scrotal mass

122
Q

Summarise the epidemiology of varicocoele

A

Unusual in boys under 10yo
Incidence increases after puberty
Incidence: 15% in general population
Associated w infertility

123
Q

What is the aetiology of varicocoele?

A

Due to venous incompetence

124
Q

What are the presenting symptoms of varicocoele?

A 
Usually asymptomatic
Only 2-10% have symptoms
Scrotum feels like bag of worms
Scrotal heaviness
Incidental finding at examination
125
Q

What are the signs of varicocoele O/E?

A

Must be standing for examination
Side of scrotum w varicocoele hangs lower
Swelling may reduce when lying down
Valsalva manoeuvre whilst standing will increase dilatation
Cough impulse

126
Q

How is varicocoele investigated?

A

Sperm count

Colour Doppler scan

127
Q

Why is varicocoele more common on the left?

A

More common on left (80-90%) bc of:

  • Angle at which left testicular vein meets left renal vein
  • Lack of effective valves between LTV and LRV
  • Increased reflux from compression of renal vein (between superior mesenteric artery and aorta)
128
Q

Why is varicocoele more common on the left?

A

More common on left (80-90%) bc of:

  • Angle at which left testicular vein meets left renal vein
  • Lack of effective valves between LTV and LRV
  • Increased reflux from compression of renal vein (between superior mesenteric artery and aorta)
129
Q

What is renal cell carcinoma?

A

Renal malignancy arising from the renal parenchyma/cortex

130
Q

Summarise the epidemiology of renal cell carcinoma

A

Majority (85%) of renal malignancies = RCC

Accounts for 2-3% of all new cancers globally

6th-8th most common adult malignancy

Of true RCCs, 80% = renal cell adenocarcinomas of clear cell histology, 12-15% are papillary tumours

Incidence rates increasing in Europe and NA, especially among women and Africans

2x many men vs women
Men have worse prognosis as present later

131
Q

What are the risk factors for renal cell carcinoma?

A 
Smoking
Male
55-84yo
Living in developed country
Black or native American
Obesity
HTN
FHx (4x)
Hx of hereditary syndrome (VHL syndrome)
Hx of dialysis
Occupational exposure to toxins: asbestos, cadmium, petroleum
High parity
Ionising raditaion syndrome
132
Q

What are the presenting symptoms for renal cell carcinoma?

A

50% asymptomatic
Haematuria
<10% triad: haematuria + flank pain + palpable abdominal mass = locally advanced disease

Non-specific systemic: fever, weight loss, sweats, pallor, cachexia, myoneuropathy

133
Q

What are the signs of renal cell carcinoma O/E?

A 
Flank tenderness
Palpable abdominal mass
Fever
Cachexia
Hepatic dysfunction: ascites, hepatomegaly, spider angiomata
Myoneuropahty
Lower limb oedema
134
Q

How is renal cell carcinoma investigated?

A

FBC: paraneoplastic syndrome = reduced Hb or elevated RBC

LDH: advanced RCC = >1.5x upper limit of normal

Corrected Ca: advanced RCC = >2.5 mmol/L

LFTs: metastatic disease/paraneoplastic syndrome = abnormal

Coagulation profile: PNPS = elevated PT

Creatinine: elevated w reduced creatinine clearance

Urinanalysis: haematuria and/or proteinuria

Abdopelvis US: abnormal renal cyst/mass, lymphadenopathy, and/or other visceral metastatic lesions

CT abdopelvis: as for US; contrast enhanced

MRI abdopelvis: as for US but modality of choice where contrast dye CI (renal insufficiency/allergy)

135
Q

Summarise the epidemiology of bladder cancer

A

9th in worldwide cancer incidence

Egypt, Western Europe, and NA have highest incidence rates

Asian countries have lowest rates

More than 90% of new cases occur in people >55yo

136
Q

What are the risk factors for bladder cancer?

A 
Smoking
Exposure to chemical carcinogens
Age >55
Pelvic radiation
Systemic chemotherapy: cyclophosphamide
Schistosoma infection
Male 4x
Chronic bladder inflammation: stones, UTI
FHx
137
Q

What are the presenting symptoms of bladder cancer?

A

Haematuria (gross, painless, present throughout entire stream)
Dysuria
Urinary frequency

138
Q

How is bladder cancer investigated?

A

Urinanalysis: RBC casts and crenated red cells w glomerular bleeding; gross/microscopic haematuria; pyuria

Urine cytology: +ve

Renal and bladder US/CT urogram.: tumour/obstruction

Cystoscopy: visualises tumours and path diagnosis

FBC: normal/mild anaemia

139
Q

What is prostate cancer?

A

A malignant tumour of glandular origin, situated in the prostate

140
Q

Summarise the epidemiology of prostate cancer

A

6th leading cause of cancer mortality in US

Adenocarcinoma is most commonly diagnosed non-cutaneous neoplasm of men in US

Median age at diagnosis = 66

Australia and New Zealand = highest rates

141
Q

What is the aetiology of prostate cancer?

A

Unknown but theorised:

  • High-fat diet
  • Genetic factors
  • ?Hormonal influence
142
Q

What are the risk factors for prostate cancer?

A

> 50yo
Black
NA or northwest European descent
FHx

143
Q

What are the presenting symptoms of prostate cancer?

A

Nocturia
Urinary frequency
Urinary hestitancy
Dysuria

144
Q

What are the signs of prostate cancer O/E?

A

Asymmetrical, nodular prostate on DRE

145
Q

How is prostate cancer investigated?

A

Serum PSA > 4 micrograms/L or >4 nanograms/mL

Testosterone: normal

LFTs: normal

FBC: normal

Renal function; normal

Prostate biopsy: malignant cells

146
Q

Summarise the epidemiology of testicular cancer

A

Most common malignancy in young adult men (20-34yo)

147
Q

What are the risk factors for testicular cancer?

A 
20-34yo
Cryptochidism
Gonadal dysgenesis
FHx
Personal Hx
White
148
Q

What are the presenting symptoms of testicular cancer?

A 
Painless swelling in one testicle
Change in shape/texture of testicle
Increased firmess of testicle
Difference between testicles
Dull ache/sharp pain in testicles or scrotum
Feeling of heaviness in scrotum
149
Q

What are the signs of testicular cancer O/E?

A

Painless (85%) testicular mass

150
Q

How is testicular cancer investigated?

A

US (colour Doppler) of testis: testicular mass

CT abdopelvis: enlarged retroperitoneal LNs

Serum beta-hCG: elevated >0.7 IU/L in choriocarcinoma

Serum alpha-fetoprotein: >25 microgram/L

Serum LDH: >25 U/L

151
Q

How is testicular cancer investigated?

A

US (colour Doppler) of testis: testicular mass

CT abdopelvis: enlarged retroperitoneal LNs

Serum beta-hCG: elevated >0.7 IU/L in choriocarcinoma

Serum alpha-fetoprotein: >25 microgram/L

Serum LDH: >25 U/L

152
Q

What is urinary catheterisation?

A

Insertion of a latex, polyurethane or silicone tube into a patient’s bladder via the urethra

153
Q

What are the indications for urinary catheterisation?

A

Intermittent:

  • Sterile urine sample
  • Relief from bladder distention
  • Bladder decompression
  • Measure residual urine
  • Mx of pt w SCI, NM degeneration, or incompetent bladder

Short-term indwelling:

  • Post surgery and in critically ill patients to monitor output
  • Acute urinary retention: BPH, blood clots
  • Instillation of meds into bladder
  • Pelvic/abdo surgery repair of bladder, urethra, surrounding structures

Long-term indwelling:

  • Refractory bladder outlet obstruction
  • Neurogenic bladder w UR
  • Prolonged and chronic UR
  • Promote healing of perineal ulcers
154
Q

What are the possible complications of urinary catheterisation?

A 
Long-term catheter: UTI
Sepsis
Urethral injury
Skin breakdown
Bladder stones
Haematuria
Bladder cancer

Y3 (20 decks)

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