Renal & Urology Flashcards
What is BPH and who is most affected by it
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
What are the signs and symptoms of BPH
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
What are appropriate investigations for BPH
Urinalysis - Check for UTI PSA - Elevated for age MSU Transrectal US International prostate symptom score 0-35 Global bother score 0-6 Volume charting
Outline treatments for BPH
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
What are complications of BPH
UTI Renal insufficiency Bladder stones Haematuria Sexual dysfunction Acute urinary retention Overactive bladder
What is Epididymitis and Orchitis
Inflammation of the epididymis or testis
Most cases of either are associated with the other
What are causes of Epididymitis and Orchitis
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
What are the sign and symptoms of Epididymitis and Orchitis
Hot, Red, Swollen Hemiscrotum with tender enlargment of the epididymis or testes
Purulent discharge may present from penis
Fever
What are investigations for Epididymitis and Orchitis
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
What is the treatment for Epididymitis and Orchitis
Sexual - Ceftriaxone + Doxycycline
Non sexual - Quinolone
What are complications of Epididymitis and Orchitis
Chronic pain
Abscess formation
Gangrene
What is Testicular torsion
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
What are the signs and symptoms of Testicular torsion
Excruciating pain Sudden onset Swelling of scrotal contents Redness High ridding testicle Cresmasteric reflex absent
How would Testicular torsion be investigated
Colour doppler US - Absent or decreased blood flow in affected testicle + Whirlpool patterns
How is Testicular torsion treated
Surgery (+Orchidopexy)
+ Morphine
What are the complications of Testicular torsion
Testicular infarction Testicular atrophy Infection Impaired fertility Cosmetic deformity
What are Urinary tract calculi
Crystal deposition within the urinary tract. AKA Nephrolithiasis
What are the different types of Urinary tract calculi
Calcium oxalate: Most common
Struvite - Quite common
Urate - 5%
Cysteine - 2%
What are the causes of Urinary tract calculi
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)
Who is more likely to get Urinary tract calculi
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
What are the signs and symptoms of Urinary tract calculi
Often asymptomatic
Severe loin to groin pain and tenderness N&V Urgency Frequency Retention Haematuria
What are the appropriate investigations for Urinary tract calculi
- 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
How are Urinary tract calculi treated
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
What are complication of Urinary tract calculi
Stone:
- Infection
- Septicaemia
- Urinary retention
Ureteroscopy
- Perforation
- False passage
Lithotripsy
- Pain
- Haematuria
What are the main types of Bladder cancer
Most transitional cell carcinoma
Rarely squamous cell carcinomas - Associated with chronic inflammation - Schistosomiasis
What are risk factors for Bladder cancer
Smoking Dye exposure Cyclophosphamide treatment Pelvic irradiation Chronic UTIs Schistosomiasis Type 2 diabetes
More common in men
What are the signs and symptoms of Bladder cancer
- Painless macroscopic haematuria
- Storage symptoms (FUN)
- Recurrent UTIs
- Rarely - Ureteral obstruction
What are appropriate investigations in Bladder cancer
- Cytoscopy - Allows visualisation, biopsy and removal
- US
- Intraevenous urography
- CT/MRI for staging
What is a Hydrocoele
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
What are the causes of a Hydrocoele
Non-Communicating:
- Idiopathic
- Tumour
- Infection
- Trauma
- Post varicocelectomy
Communicating:
- Increased IA pressure/fluid + Patent processus vaginalis
- Connective tissue disorders
Biphasic (Children and elderly)
What are signs and symptoms of a Hydrocoele
- Scrotal mass (Com-Soft; NCom - Tense)
- Transilluminates
- Increased IAP = Enlargment
- Variation in mass during day = Small in morning following lying down - Communicating
What are the appropriate investigations for a Hydrocoele
Clinical diagnosis
US - Exclude tumour Urine Dip - Exclude infection Blood - Markers for testicular tumours - alpha-fetoprotein - beta-HCG - Lactase DH
What is a Varicocoele
Dilated veins of the pampiniform plexus forming a scrotal mass
What are the causes of Varicocoeles
Most common the left side
Caused by venous incompetence
Incidence increase after puberty
What are the signs and symptoms of a Varicocoele
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
What are the investigations for Varicocoeles
Clinical diagnosis
Semen analysis - Potential reduced sperm count
What are the different types of Testicular cancer
- Seminomas - 50%
- Non-semomatous germ-cell tumours and teratomas - 30%
- Rare - Gonadal stromal/Non-Hodgkin’s lymphoma
What are risk factors for Testicular cancer
Maldescended testes
Ectopic testes
Atrophic testes
Cancer affecting young men
What are the signs and symptoms of Testicular cancer
Swelling or discomfort of the testes Backache Lung metastases - SOB, Haemoptysis Secondary hydrocele Lymphadenopathy Gynaecomastia
What are the appropriate investigations in Testicular cancer
Tumour markers:
Alpha-fetoprotein
Beta-HCG
LDH
CT - Enlarged retroperitoneal lymph nodes
US Doppler - Testicular mass
CXR - Lung met
What are the types of Renal cell carcinoma
Renal clear cell carcinoma - 80%
Papillary carcinoma - 10%
Transitional cell carcinoma - 10% - Occur at the renal pelvis
What are risk factors for Renal cell carcinoma
Inherited causes: Von Hippel-Lindau disease Tuberous sclerosis Polycystic kidney disease Familial renal cancer
Smoking
Chronic dialysis
What are the signs and symptoms of Renal cell carcinoma
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
What are the appropriate investigations for Renal cell carcinoma
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
What is Renal artery stenosis
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
What are causes of Renal artery stenosis
90% are atherosclerotic
- Athersclerosis
- DM
- Dyslipidaemia
- Smoking
10% are fibromuscular dysplastic (Women more likely)
- Medical fibroplasia
- Intimal and adventitial fibroplasia
- Smoking
What are the signs and symptoms of Renal artery stenosis
Abdominal bruit
Pulmonary oedema
Other bruits
Hx of HTN, CAD, PVD or kidney dysfunction
What are appropriate investigations for Renal artery stenosis
US duplex - Reduced vessel diameter, Decreased Kidney size
Creatine High
K Low
Aldosterone/Renin <20
What are risk factors for prostate cancer
Increasing age
Afro-Caribbean
FHx
2nd most common cause of cancer death in males
What are the signs and symptoms of Prostate cancer
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
What are appropriate investigations for prostate cancer
PSA >4
Biopsy - Transrectal US guided
CT/MRI - Staging
Isotope bone scan - Check for mets
What is Polycystic kidney disease?
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.
What are the causes of Polycystic kidney disease
85% PKD1 on chromosome 16
15% PKD2 on chromosome 4
Most common inherited kidney disease
Responsible for 10% of ESRF
What are the signs and symptoms of Polycystic kidney disease
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
What are the appropriate investigations for Polycystic kidney disease
US or CT
Multiple cysts bilaterally in enlarged kidneys
Liver cysts may also be seen
ECG - LVH
CT Brain - +ve IC bleed
What is Nephrotic syndrome
This is a characteristic triad of:
- Proteinuria >3g/24hrs
- Hypoalbuminaemia <30g/L
- Oedema (Due to loss of oncotic pressure)
Also commonly involves Hypercholesterolaemia
What are the causes of Nephrotic syndrome
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
What is the most common cause of Nephrotic syndrome in adults
Membranous glomerulonephritis
Then
Diabetic nephropathy
What are the signs and symptoms of Nephrotic syndrome
- FHx - Atopy, Renal disease
- Swelling - Face, Abdomen, Limbs, Genitalia
- Ascites - Fluid thrill, Shifting dullness
What are appropriate investigations for Nephrotic syndrome
LFTs - Hypoalbuminaemia
Urinalysis - Proteinuria
Lipid profile - Hyperlipidaemia
Identify causes: SLE Infections Goodpasture's syndrome Vasculitides
What is a UTI defined as
The presence of a pure growth of >10^5 organisms per mL of fresh MSU
What are the different types of UTI
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
What are the causes of UTIs
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
What are the signs and symptoms of UTIs
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
How are UTIs investigated
- 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
What is treatment for UTIs
Uncomplicated UTI: Trimethoprin or Nitrofurantoin
Alternative treatments: Co-amoxiclav or cefalexin
Prophylactic antibiotics may be used in certain circumstances
What are complications of UTI
Ascending infection can lead to:
- Pyelonephritis
- Perinephric and infrarenal abscess
- Hydronephrosis or pyonephrosis
- AKI
- Sepsis
What is Acute kidney injury (AKI)
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
What are the different classifications for AKI
Pre-renal - Impaired perfusion
Intrinsic - Direct injury to renal parenchyma
Post-renal - Obstruction of urinary outflow
What are causes of Pre-renal AKI
90%
Hypovolaemic (Haemorrhage, severe vomiting, diarrhoea)
- CHF
- Heart failure
- Cirrhosis
- Hypotension (Sepsis, shock, anaphylaxis)
- Renovascular disease (Bilateral RAS, ACEi, ARBs, NSAIDs)
What are causes of Intrinsic AKI
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
What are causes Post-renal AKI
Calculi Intra-abdominal tumour BPH Prostate cancer Bladder tumour
What are the signs and symptoms of of AKI
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)
How is AKI diagnosed
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
How is AKI treated
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
What are complications of AKI
Volume overload
Hyperkalaemia
Metabolic acidosis
Hyperphosphataemia
Uraemia
C-Progressive-KD
ESRD
What is Chronic kidney disease (CKD)
Pathological abnormality of the kidney that develops over greater than 3 months
eGFR <60ml/min/1.73m2 for greater than 3 months
Haematuria
Proteinuria
What are the classification of CKD
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
What are causes of CKD
Increasing age DM - Most common cause HTN - 2nd Most common cause Obesity CVD
Other SLE Nephropathies FHx Neoplasia Myeloma Smoking
What are signs and symptoms of CKD
N & V Anorexia Pruritus Oedema Arthralgia Muscle cramps
Signs:
Pallor
HTN
Peripheral oedema
How is CKD diagnosed
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
What is Glomerulonephritis
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
What are the clinical syndromes that can be produced by Glomerulonephritis
Nephrotic: Heavy proteinuria, Hypoalbuminaemia, fluid retention
Nephritic: Haematuria, Proteinuria, a fall in eGFR, salt and water retention and HTN
List all the Glomerulonephritis according to the clinical syndrome they tend to cause
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
Outline Minimal change disease
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
Outline Focal segmental glomerulosclerosis
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
Outline Membranous nephropathy
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
Outline IGA Nephropathy (Berger’s disease)
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
Outline Membranoproliferative (Mesangiocapillary) glomerulonephritis
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.
Outline Post infectious (Diffuse proliferative) glomerulonephritis
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
Outline Crescenteric glomerulonephritis
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
