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All conditions - Year 3 > Renal & Urology > Flashcards

Renal & Urology Flashcards

1
Q

What is BPH and who is most affected by it

A

This the benign hyperplasia (Increase in cell number) of the peri-urethral (transitional) zone of the prostate gland

It is very common and prevalence increases with age

Black men
Western

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2
Q

What are the signs and symptoms of BPH

A

LUT symptoms

Storage (FUN)

  • Frequency
  • Urgency
  • Nocturia

Voiding (WHIIPS)

  • Weak stream
  • Hesitancy
  • Incomplete voiding
  • Intermittency
  • Post void dribble
  • Straining

Potential:
Dysuria
Retention

DRE - Smoothly enlarged with palpable midline groove

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3
Q

What are appropriate investigations for BPH

A 
Urinalysis - Check for UTI
PSA - Elevated for age
MSU
Transrectal US
International prostate symptom score 0-35
Global bother score 0-6
Volume charting
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4
Q

Outline treatments for BPH

A

Non-bothersome - WW

Bothersome no surgery (Medical)

  • Alpha-blocker - Doxazosin
  • 5-alpha reductase inhibitor - Finasteride
  • PDE-5 inhibitor - Sildenafil
  • Anticholinergic

Small surgical

  • Minimally invasive - TUMT, TUNA, PUL
  • Moderately invasive - TURP, TUVP, Laser vaporisation

Large surgical
- Open prostatectomy

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5
Q

What are complications of BPH

A 
UTI
Renal insufficiency
Bladder stones
Haematuria
Sexual dysfunction
Acute urinary retention
Overactive bladder
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6
Q

What is Epididymitis and Orchitis

A

Inflammation of the epididymis or testis

Most cases of either are associated with the other

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7
Q

What are causes of Epididymitis and Orchitis

A

Most cases are due to infective causes.

In those younger than 35 this would be Chlamydia or Gonorrhea

In those older than 35 this would be Urinary tract pathogens

Viral - Mumps
Fungal - Candida

1/3 Idiopathic

RFs: Vasculitis, Unprotected sex, Amiodarone

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8
Q

What are the sign and symptoms of Epididymitis and Orchitis

A

Hot, Red, Swollen Hemiscrotum with tender enlargment of the epididymis or testes

Purulent discharge may present from penis

Fever

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9
Q

What are investigations for Epididymitis and Orchitis

A

Gram stain of urethral secretions >5 WCC

Urine dip - WCC
Urine microscopy - WCC
Urine culture - Isolate of causative organism

Colour duplex US - Increased blood flow - Excludes TT

Surgical exploration - If TT can not be excluded

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10
Q

What is the treatment for Epididymitis and Orchitis

A

Sexual - Ceftriaxone + Doxycycline

Non sexual - Quinolone

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11
Q

What are complications of Epididymitis and Orchitis

A

Chronic pain
Abscess formation
Gangrene

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12
Q

What is Testicular torsion

A

A urological emergency caused by the twisting to the testicles/spermatic cord. There is constriction of vascular supply and there is time sensitive’s ischaemia that will lead to necrosis if left for too long.

Caused by trauma +/- thev bell clapper deformity

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13
Q

What are the signs and symptoms of Testicular torsion

A 
Excruciating pain
Sudden onset
Swelling of scrotal contents
Redness
High ridding testicle
Cresmasteric reflex absent
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14
Q

How would Testicular torsion be investigated

A

Colour doppler US - Absent or decreased blood flow in affected testicle + Whirlpool patterns

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15
Q

How is Testicular torsion treated

A

Surgery (+Orchidopexy)

+ Morphine

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16
Q

What are the complications of Testicular torsion

A 
Testicular infarction
Testicular atrophy
Infection
Impaired fertility 
Cosmetic deformity
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17
Q

What are Urinary tract calculi

A

Crystal deposition within the urinary tract. AKA Nephrolithiasis

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18
Q

What are the different types of Urinary tract calculi

A

Calcium oxalate: Most common
Struvite - Quite common
Urate - 5%
Cysteine - 2%

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19
Q

What are the causes of Urinary tract calculi

A

Many cases are idiopathic

Metabolic - Hyper:

  • Calcuria - Ca
  • Uricaemia - Urea
  • Cystinuria - Cystine
  • Oxaluria - Oxalate

Infection leading to Hyperuricaemia

Drugs - Indinavir

RFs: Low fluid intake, Structural urinary tract abnormalities (Horseshoe kidney)

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20
Q

Who is more likely to get Urinary tract calculi

A

They are very common - 2-3% of people
3x more common in males
Upper urinary tract stones more common in industrialised countries
Bladder stones more common in developing countries

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21
Q

What are the signs and symptoms of Urinary tract calculi

A

Often asymptomatic

Severe loin to groin pain and tenderness
N&V
Urgency
Frequency
Retention
Haematuria
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22
Q

What are the appropriate investigations for Urinary tract calculi

A
  • Urine dip - Haematuria
  • X-ray - 80% of kidney stones are radio-opaque
  • IV urography - Visualisation of the kidney and ureters
  • Non-enhanced spiral CT - Can also be used to imagine stones
  • Isotope radiography - Used to assess kidney function
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23
Q

How are Urinary tract calculi treated

A

Supportive:
- Hydration (Crystalloid) + Analgesia + Anti-emetics
+ Evidence of infection - Antibiotics

Removing the stone:

  • Urethroscopy - Direct removal or if unsuccessful stent placement
  • Extracorporeal shock-wave lithotripsy - Breaks down stone so it can be passed
  • Percutaneous nephrolithotomy - Large complex stones
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24
Q

What are complication of Urinary tract calculi

A

Stone:

  • Infection
  • Septicaemia
  • Urinary retention

Ureteroscopy

  • Perforation
  • False passage

Lithotripsy

  • Pain
  • Haematuria
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25
Q

What are the main types of Bladder cancer

A

Most transitional cell carcinoma

Rarely squamous cell carcinomas - Associated with chronic inflammation - Schistosomiasis

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26
Q

What are risk factors for Bladder cancer

A 
Smoking
Dye exposure
Cyclophosphamide treatment
Pelvic irradiation
Chronic UTIs
Schistosomiasis
Type 2 diabetes

More common in men

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27
Q

What are the signs and symptoms of Bladder cancer

A
  • Painless macroscopic haematuria
  • Storage symptoms (FUN)
  • Recurrent UTIs
  • Rarely - Ureteral obstruction
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28
Q

What are appropriate investigations in Bladder cancer

A
  • Cytoscopy - Allows visualisation, biopsy and removal
  • US
  • Intraevenous urography
  • CT/MRI for staging
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29
Q

What is a Hydrocoele

A

A excessive collection of serous fluid within the tunica vaginalis - Membranous layer souring the testis and spermatic cord

It can be communicating (Leading to an inguinal hernia) or it can be non-communicating

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30
Q

What are the causes of a Hydrocoele

A

Non-Communicating:

  • Idiopathic
  • Tumour
  • Infection
  • Trauma
  • Post varicocelectomy

Communicating:

  • Increased IA pressure/fluid + Patent processus vaginalis
  • Connective tissue disorders

Biphasic (Children and elderly)

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31
Q

What are signs and symptoms of a Hydrocoele

A
  • Scrotal mass (Com-Soft; NCom - Tense)
  • Transilluminates
  • Increased IAP = Enlargment
  • Variation in mass during day = Small in morning following lying down - Communicating
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32
Q

What are the appropriate investigations for a Hydrocoele

A

Clinical diagnosis

US - Exclude tumour
Urine Dip - Exclude infection
Blood - Markers for testicular tumours
- alpha-fetoprotein
- beta-HCG
- Lactase DH
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33
Q

What is a Varicocoele

A

Dilated veins of the pampiniform plexus forming a scrotal mass

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34
Q

What are the causes of Varicocoeles

A

Most common the left side

Caused by venous incompetence

Incidence increase after puberty

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35
Q

What are the signs and symptoms of a Varicocoele

A

Usually asymptomatic

  • Scrotum feeling like bag of worms
  • Scrotal heaviness
  • Incidental finding at examination
  • Patient must be standing
  • The side with the varicocele will hang lower
  • Swelling may reduce when lying down
  • Valsalva manoeuvre while standing will increase dilation
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36
Q

What are the investigations for Varicocoeles

A

Clinical diagnosis

Semen analysis - Potential reduced sperm count

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37
Q

What are the different types of Testicular cancer

A
  • Seminomas - 50%
  • Non-semomatous germ-cell tumours and teratomas - 30%
  • Rare - Gonadal stromal/Non-Hodgkin’s lymphoma
38
Q

What are risk factors for Testicular cancer

A

Maldescended testes
Ectopic testes
Atrophic testes

Cancer affecting young men

39
Q

What are the signs and symptoms of Testicular cancer

A 
Swelling or discomfort of the testes
Backache
Lung metastases - SOB, Haemoptysis
Secondary hydrocele
Lymphadenopathy
Gynaecomastia
40
Q

What are the appropriate investigations in Testicular cancer

A

Tumour markers:
Alpha-fetoprotein
Beta-HCG
LDH

CT - Enlarged retroperitoneal lymph nodes
US Doppler - Testicular mass
CXR - Lung met

41
Q

What are the types of Renal cell carcinoma

A

Renal clear cell carcinoma - 80%
Papillary carcinoma - 10%
Transitional cell carcinoma - 10% - Occur at the renal pelvis

42
Q

What are risk factors for Renal cell carcinoma

A 
Inherited causes:
Von Hippel-Lindau disease
Tuberous sclerosis
Polycystic kidney disease
Familial renal cancer

Smoking
Chronic dialysis

43
Q

What are the signs and symptoms of Renal cell carcinoma

A

Renal clear cell carcinoma:

  • Usually late presentation
  • Asymptomatic in 90%
  • Triad of Haematuria, Flank Pain, Abdominal mass

Transitional cell carcinoma:
- Earlier presentation with haematuria

Palpable renal mass
HTN
Plethora
Anaemia
Potential varicocele - left side 
Weight loss
Malaise
Paraneoplastic syndromes
44
Q

What are the appropriate investigations for Renal cell carcinoma

A 
FBC: Anaemia and polycythaemia
LDH: Elevated
LFTs: Elevated in metastatic disease
Creatinine - Elevated
Urinalysis - Haematuria and Proteinuria

US - Renal mass
CT - Definitive - Staging Robson staging

45
Q

What is Renal artery stenosis

A

This is narrowing of the renal artery lumen by 50% leading to a reduced GFR (Causing Ischaemic nephropathy) and renovascular hypertension dye to RAS activation as there is underperfusion of the kidney

46
Q

What are causes of Renal artery stenosis

A

90% are atherosclerotic

  • Athersclerosis
  • DM
  • Dyslipidaemia
  • Smoking

10% are fibromuscular dysplastic (Women more likely)

  • Medical fibroplasia
  • Intimal and adventitial fibroplasia
  • Smoking
47
Q

What are the signs and symptoms of Renal artery stenosis

A

Abdominal bruit
Pulmonary oedema
Other bruits
Hx of HTN, CAD, PVD or kidney dysfunction

48
Q

What are appropriate investigations for Renal artery stenosis

A

US duplex - Reduced vessel diameter, Decreased Kidney size

Creatine High
K Low
Aldosterone/Renin <20

49
Q

What are risk factors for prostate cancer

A

Increasing age
Afro-Caribbean
FHx

2nd most common cause of cancer death in males

50
Q

What are the signs and symptoms of Prostate cancer

A

LUTs (FUN WHIIPS)

  • Frequency
  • Urgency
  • Nocturia
  • Weak stream
  • Hesistancy
  • Intermittency
  • Incomplete voiding
  • Post void dribble
  • Straining

Metastatic spread

  • Bone pain
  • Cord compression
  • Malaise, Anorexia, Weight loss
  • Paraneoplastic syndrome

DRE - Loss of midline sulcus + Asymmetrical hard nodular prostate

51
Q

What are appropriate investigations for prostate cancer

A

PSA >4
Biopsy - Transrectal US guided
CT/MRI - Staging
Isotope bone scan - Check for mets

52
Q

What is Polycystic kidney disease?

A

This is an autosomal dominant (More common)/Autosomal recessive disorder that results in the development of multiple renal cysts that gradually expand and replace normal kidney substance.

53
Q

What are the causes of Polycystic kidney disease

A

85% PKD1 on chromosome 16
15% PKD2 on chromosome 4

Most common inherited kidney disease
Responsible for 10% of ESRF

54
Q

What are the signs and symptoms of Polycystic kidney disease

A 
Present at age 30-40
20% Have no FHx
Flank pain
Haematuria
HTN
Berry aneurysms and may present with SAH
Abdominal distension
Enlarged cystic kidneys
Palpable liver
Signs of Chronic renal failure
Signs of AAA or Aortic valve disease
55
Q

What are the appropriate investigations for Polycystic kidney disease

A

US or CT
Multiple cysts bilaterally in enlarged kidneys
Liver cysts may also be seen

ECG - LVH
CT Brain - +ve IC bleed

56
Q

What is Nephrotic syndrome

A

This is a characteristic triad of:

  • Proteinuria >3g/24hrs
  • Hypoalbuminaemia <30g/L
  • Oedema (Due to loss of oncotic pressure)

Also commonly involves Hypercholesterolaemia

57
Q

What are the causes of Nephrotic syndrome

A

It is most commonly caused by minimal change glomerulonephritis in children (90% of cases)

All types of glomerulonephritis can cause nephrotic syndrome

Other causes:

  • DM
  • Sickle cell disease
  • Amyloidosis
  • Lung cancer
  • GI adenocarcinoma
  • Drugs (NSAIDs)
  • Alport’s syndrome
  • HIV
  • SLE
58
Q

What is the most common cause of Nephrotic syndrome in adults

A

Membranous glomerulonephritis

Then

Diabetic nephropathy

59
Q

What are the signs and symptoms of Nephrotic syndrome

A
  • FHx - Atopy, Renal disease
  • Swelling - Face, Abdomen, Limbs, Genitalia
  • Ascites - Fluid thrill, Shifting dullness
60
Q

What are appropriate investigations for Nephrotic syndrome

A

LFTs - Hypoalbuminaemia
Urinalysis - Proteinuria
Lipid profile - Hyperlipidaemia

Identify causes:
SLE
Infections
Goodpasture's syndrome
Vasculitides
61
Q

What is a UTI defined as

A

The presence of a pure growth of >10^5 organisms per mL of fresh MSU

62
Q

What are the different types of UTI

A

Lower - Affecting the urethra, bladder or prostate
Upper - Affecting the renal pelvis

Uncomplicated - Normal renal tract and function
Complicated - Abnormal renal/genitourinary tract, voiding difficulty/obstruction, reduced renal function, impaired host defences, virulent organism

63
Q

What are the causes of UTIs

A

Most common cause is E. coli

Other causative organisms:

  • S aureus
  • Proteus mirabilis
  • Enterococci

Atypical organisms that can cause UTI:

  • Klebsiella
  • Candida albicans
  • Pseudomonas aeruginosa

RFs:

  • Female
  • Sex
  • Pregnancy
  • Menopause
  • Immunosuppression
  • Catheterisation
  • Urinary tract obstruction
  • Urinary tract malformation
64
Q

What are the signs and symptoms of UTIs

A

Cystitis

  • Frequency
  • Urgency
  • Dysuria
  • Haematuria
  • Suprapubic pain

Prostatitis

  • Flu-like symptoms
  • Low backache
  • Few urinary symptoms
  • Swollen or tender prostate on DRE

Acute pyelonephritis

  • High fever with rigors
  • Vomiting
  • Loin pain and tenderness
  • Oliguria

Foul smelling urine

65
Q

How are UTIs investigated

A
  • Urine dipstick - +ve leucocyte esterase and nitrates
  • Microscopy - Presence of leucocytes indicates infection
  • Culture - Exclude diagnosis or if the patient failed to respond to empirical antibiotics
  • US - Rule out obstruction
  • Bloods - U&Es
66
Q

What is treatment for UTIs

A

Uncomplicated UTI: Trimethoprin or Nitrofurantoin

Alternative treatments: Co-amoxiclav or cefalexin

Prophylactic antibiotics may be used in certain circumstances

67
Q

What are complications of UTI

A

Ascending infection can lead to:

  • Pyelonephritis
  • Perinephric and infrarenal abscess
  • Hydronephrosis or pyonephrosis
  • AKI
  • Sepsis
68
Q

What is Acute kidney injury (AKI)

A

This is an acute decline in renal function resulting in retention of urea and creatinine and a decrease in urine output (Dysregulation of extracellular volume)

Any of the following
Serum creatinine >26.5 within 48 hours
Serum Urea >1.5x baseline within 7 days
Urine Volume <0.5ml/kg/hr for 6 hours

69
Q

What are the different classifications for AKI

A

Pre-renal - Impaired perfusion
Intrinsic - Direct injury to renal parenchyma
Post-renal - Obstruction of urinary outflow

70
Q

What are causes of Pre-renal AKI

A

90%
Hypovolaemic (Haemorrhage, severe vomiting, diarrhoea)
- CHF
- Heart failure
- Cirrhosis
- Hypotension (Sepsis, shock, anaphylaxis)
- Renovascular disease (Bilateral RAS, ACEi, ARBs, NSAIDs)

71
Q

What are causes of Intrinsic AKI

A

Tubular: Acute tubular necrosis - Usually secondary to a prerenal decrease in profusion
- Nephrotoxins: Aminoglycosides, Heavy metals, Myoglobin, Ethylene glycol, Radiocontrast dye, Uric acid (Tumour lysis syndrome)

Glomerular

  • Glomerulonephritis
  • Haemolytic uraemia syndrome

Interstitial:
- Acute interstitial nephritis (NSAIDs, Penicillin, Diuretics)
Can lead to renal papillary necrosis

Vasculitides (Wegner’s)
Eclampsia

72
Q

What are causes Post-renal AKI

A 
Calculi
Intra-abdominal tumour
BPH
Prostate cancer
Bladder tumour
73
Q

What are the signs and symptoms of of AKI

A

Pre-renal:

  • Oligouria/Anuria
  • Thirst, Dizziness, Tachycardia
  • Orthopnoea/PND

Intrinsic:

  • Oliguria (Decreased GFR)
  • HTN (Glomerular)
  • Oedema (Glomerular)
  • Fever (Interstitial)
  • Rash (Interstitial)
  • Flank pain (Interstitial)

Post-renal:
- Oliguria (Decreased GFR)

74
Q

How is AKI diagnosed

A

Pre-renal:

  • BUN:Creatinine >20:1
  • Urine Na <20
  • FEna <1%
  • Urine osmolality >500
  • Azotemia

Intrinsic:

  • Hyperkalaemia
  • Metabolic acidosis
  • Azotemia
  • Urinalysis: Cellular casts, Protein (Glomerular), Haematuria (Glomerular and Interstitial)
  • Eosinophilia (Interstital - Hypersensitivity 1 or 4)
  • BUN:Creatinine <15:1
  • Urine Na >40
  • FEna >2%
  • Urine osmolality <350

Post-renal:
- Azotemia
Initial Pre-renal picture. Later Intrinsic picture

  • US look for post-renal cause/hydronephrosis
  • Immunology: ANA, A-DNA, Complement, Anti-GBM, Anti-NCA
  • Serology: Hep and HIV
75
Q

How is AKI treated

A

Pre-renal:
- Volume expansion + Tranfusion - Normal saline, Ringers, Colloid
- Vasopressor - Treats hypotension - Dopamine, Adrenaline, NA,
A - Diuretics - Furosemide
A - Renal replacement therapy - Haemodialysis

Intrinsic:
-Treat underlying cause
A - Diuretics - Furosemide
A - Volume expansion + Tranfusion - Normal saline, Ringers, Colloid
A - Renal replacement therapy - Haemodialysis

Post-renal
1 - Bladder catheterisation
2 - Relief of obstruction above bladder neck
A - Diuretics - Furosemide
A - Renal replacement therapy - Haemodialysis

76
Q

What are complications of AKI

A

Volume overload
Hyperkalaemia
Metabolic acidosis
Hyperphosphataemia

Uraemia
C-Progressive-KD
ESRD

77
Q

What is Chronic kidney disease (CKD)

A

Pathological abnormality of the kidney that develops over greater than 3 months

eGFR <60ml/min/1.73m2 for greater than 3 months
Haematuria
Proteinuria

78
Q

What are the classification of CKD

A 
Stage 1: >90 with other evidence of CKD
Stage 2: 60-89
Stage 3a: 45-59
Stage 3b: 30-44
Stage 4: 15-29
Stage 5: <15 or on dialysis
79
Q

What are causes of CKD

A 
Increasing age
DM - Most common cause
HTN - 2nd Most common cause
Obesity
CVD
Other
SLE
Nephropathies
FHx
Neoplasia
Myeloma
Smoking
80
Q

What are signs and symptoms of CKD

A 
N &amp; V
Anorexia
Pruritus
Oedema
Arthralgia
Muscle cramps

Signs:
Pallor
HTN
Peripheral oedema

81
Q

How is CKD diagnosed

A

Bloods:

  • Hyperkalaemia
  • Hypocalcaemia
  • Monitor eGFR over time
  • Creatinine

Urinalysis - Proteinuria and Haematuria

Renal US to see kidney size, mass lesions, obstructions and renal arterial blood flow

Biopsy to look for pathological diagnosis

82
Q

What is Glomerulonephritis

A

This is a tangle of immune-mediated disorders that cause inflammation within the glomerulus

1o - No associate systemic disease
2o - Glomerular involvement is part of a systemic disease

83
Q

What are the clinical syndromes that can be produced by Glomerulonephritis

A

Nephrotic: Heavy proteinuria, Hypoalbuminaemia, fluid retention

Nephritic: Haematuria, Proteinuria, a fall in eGFR, salt and water retention and HTN

84
Q

List all the Glomerulonephritis according to the clinical syndrome they tend to cause

A

Nephrotic syndrome (Non-Proliferative)

  • Minimal change disease
  • Focal segmental glomerulosclerosis
  • Membranous glomerulonephritis

Nephritic syndrome (Proliferative)

  • IGA Nephropathy
  • Membranoproliferative glomerulonephritis
  • Post infectious glomerulonephritis
  • Rapidly progressive (Crescentic) glomerulonephritis
85
Q

Outline Minimal change disease

A

Commonly affecting children
Most common cause of nephrotic syndrome in children

Can be secondary to Hodgkin’s lymphoma

Normal renal function
Normal blood pressure
Normal complement levels

Increased risk of infections
Renal biopsy: Electron microscopy shows fusion of podocytes

86
Q

Outline Focal segmental glomerulosclerosis

A

Asymptomatic or may have oedema - Associated with HIV

Patient may have HTN but otherwise the examination is unremarkable

Young adults

Renal biopsy: Focal and segmental sclerosis (scaring) + Podocyte fusion

87
Q

Outline Membranous nephropathy

A

Most common cause of nephrotic syndrome in adults - More common in men

Renal biopsy: Thickening of BM
Immunofluorescence: Granular deposits of immunoglobulin and complement

Most idiopathic

Some secondary to SLE, HEP B, malignancy, syphilis or the use of rheumatoid drugs

88
Q

Outline IGA Nephropathy (Berger’s disease)

A

Mesangial cell proliferation combined with matrix expansion

Commonest cause of glomerulonephritis worldwide

Mesangial deposition of IgA immune complexes

Henoch-Schonlein purpura

Young male with recurrent episodes of macroscopic haematuria

Associated with seronegative arthropathy, coeliac disease

Renal biopsy: IgA deposits seen on immunofluorescent examination of renal biopsy

89
Q

Outline Membranoproliferative (Mesangiocapillary) glomerulonephritis

A

May present with nephrotic syndrome or nephritic syndrome in children and young adults.

Renal biopsy: Proliferation of mesangial cells, an increase in mesangial matrix and thickening of the glomerular basement membrane.

Subdivided according to appearance on electron microscopy

Associated with low levels of C3.

90
Q

Outline Post infectious (Diffuse proliferative) glomerulonephritis

A

Generally presents with an acute nephritic syndrome/ acute kidney injury two or more weeks after an infection.

Classically caused by streptococcal infection.

Rare in developed countries but post-streptococcal glomerulonephritis remains common in the developing world.

Almost all children will recover without treatment (other than antibiotics for the infection); however, a small proportion of adults may develop renal impairment.

Renal biopsy: Mesangial
and endothelial cell proliferation over all glomeruli

91
Q

Outline Crescenteric glomerulonephritis

A

Seen in the following conditions:

  • Goodpastures syndrome
  • Wegners granulmatosis
  • Microscopic polyangiitis

It is rapidly progressive glomerulonephritis often presenting as acute kidney injury

Goodpastures:

  • Haemoptysis
  • Haematuria
  • Often positive smoking Hx
  • Crackles on auscultation

Anti-GBM antibody - Positive
CXR - Pulmonary haemorrhage
Renal biopsy: Cresentic, Non-proliferative glomerulonephritis, linear IgG glomerular BM

All conditions - Year 3 (16 decks)

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