Renal & Urology Flashcards
1
Q
Learning objectives
A
Answer
2
Q
Define acute kidney injury (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.
o NOTE: this can occur in patients with previously normal kidneys or in patients with pre-existing renal disease
• KDIGO Classification of AKI
o Increase in serum creatinine > 26 mol/L within 48 hrs
o Increase in serum creatinine to > 1.5 times baseline within the preceding 7 days
o Urine volume < 0.5 ml/kg/hr for 6 hours nine >26 umol/l within 48 hours/ to >1.5 times baseline within the preceeding 7 days/ urine volume <0.5 ml/kg/hr for 6 hours
3
Q
Explain the aetiology / risk factors of acute kidney injury (AKI)
A
Pre renal (90%) - Hypovolaemia (e.g. haemorrhage, severe vomiting), heart failure, cirrhosis, nephrotic syndrome, hypotension (e.g. shock, sepsis, anaphylaxis), renal hypoperfusion (e.g. NSAIDs, ACE inhibitors, ARBs, renal artery stenosis). Intrinsic renal - glomerular - glomerulonephritis, haemolytic yuraemic syndrome, Tubular - acute interstitial necrosis, Interstitial (e.g. NSAIDs, autoimmune), Vasculitides (e.g. Wegener’s granulomatosis), Eclampsia. Post renal (due to obstruction) - Calculi, Urethral Structure, Prostatic hypertrophy or malignancy, Bladder tumour. Risk Factors: Age, CKD, Comorbidities (e.g HF), Sepsis, Hypovolaemia, Use of nephrotoxis medications, Emergency surgery, Diabetic mellitus
4
Q
Summarise the epidemiology of acute kidney injury (AKI)
A
15% of adults admitted to hospital. Most common in the elderly.
5
Q
Recognise the presenting symptoms of acute kidney injury (AKI)
A
Dependent on the underlying cause. Oligura/anuria (abrupt anuria suggests post-renal obstruction. Nausea/vomiting, dehydration, confusion
6
Q
Recognise the signs of acute kidney injury (AKI) on physical examination
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)
7
Q
Identify appropriate investigations for acute kidney injury (AKI) and interpret the results
A
Urinalysis - blood (suggests nephritic cause), Leucocyte esterase and nitrites - UTI, Glucose, Protein, Urine osmolality. Bloods - FBC, Blood Film, U & Es, Clotting, CRP, Immunology - • Serum immunoglobulins and protein electrophoresis - for multiple myeloma - Also check for Bence-Jones proteins in the urine
• ANA - associated with SLE - Also check anti-dsDNA antibodies (high in active lupus)
• Complement levels - low in active lupus
• Anti-GBM antibodies - Goodpasture’s syndrome
• Antistreptolysin-O antibodies - high after Streptococcal infection . Virology- Hep & HIV, Ultrasound - Post renal cause - look for hydronephrosis, CXR - Pulmonary Oedema, AXR - Renal stones
8
Q
Generate a management plan for acute kidney injury (AKI)
A
Treat the cause
FOUR main components to management:
o Protect patient from hyperkalaemia (calcium gluconate)
o Optimise fluid balance
o Stop nephrotoxic drugs
o Consider for dialysis
Monitor serum creatinine, sodium, potassium, calcium, phosphate and glucose
Identify and treat infection
Urgent relief of urinary tract obstruction
Refer to nephrology if intrinsic renal disease is suspected
Renal Replacement Therapy (RRT) considered if:
o Hyperkalaemia refractory to medical management
o Pulmonary oedema refractory to medical management
o Severe metabolic acidaemia
o Uraemic complications
9
Q
Identify the possible complications of acute kidney injury (AKI) and its management
A
- Pulmonary oedema
- Acidaemia
- Uraemia
- Hyperkalaemia
- Bleeding
10
Q
Summarise the prognosis for patients with acute kidney injury (AKI)
A
Inpatient mortality varies depending on cause and comorbidities Indicators of poor prognosis: o Age o Multiple organ failure o Oliguria o Hypotension o CKD Patients who develop AKI are at increased risk of developing CKD
11
Q
Define amyloidosis
A
• Heterogenous group of diseases characterised by extracellular deposition of amyloid fibrils
12
Q
Explain the aetiology / risk factors of amyloidosis
A
• Amyloid fibrils are polymers of low-molecular-weight subunit proteins
• These are derived from proteins that undergo conformational changes to adopt an anti-parallel beta-pleated sheet configuration
• Their deposition progressively disrupts the structure and function of normal tissue
• Amyloidosis is classified according to the fibril subunit proteins
o Type AA - serum amyloid A protein
o Type AL - monoclonal immunoglobulin light chains
o Type ATTR (familial amyloid polyneuropathy) - genetic-variant transthyretin
13
Q
Summarise the epidemiology of amyloidosis
A
- AA - incidence of 1-5% amongst patients with chronic inflammatory diseases
- AL - 300-600 cases in the UK per year
- Hereditary Amyloidosis - accounts for 5% of patients with amyloidosis
14
Q
Recognise the presenting symptoms & signs of amyloidosis
A
- Renal - proteinuria, nephrotic syndrome, renal failure
- Cardiac - restrictive cardiomyopathy, heart failure, arrhythmia, angina
- GI - macroglossia (characteristic of AL), hepatosplenomegaly, gut dysmotility, malabsorption, bleeding
- Neurological - sensory and motor neuropathy, autonomic neuropathy, carpal tunnel syndrome
- Skin - waxy skin and easy bruising, purpura around the eyes (characteristic of AL), plaques and nodules
- Joints - painful asymmetrical large joints, enlargement of anterior shoulder
- Haematological - bleeding tendency
15
Q
Identify appropriate investigations for amyloidosis and interpret the results
A
• Tissue Biopsy • Urine - check for proteinuria, free immunoglobulin light chains (in AL) • Bloods o CRP/ESR o Rheumatoid factor o Immunoglobulin levels o Serum protein electrophoresis o LFTs o U&Es • SAP Scan - radiolabelled SAP will localise the deposits of amyloid
16
Q
Define benign prostatic hyperplasia
A
- Slowly progressive nodular hyperplasia of the periurethral (transitional) zone of the prostate gland
- It is the most frequent cause of LUTS in adult males
17
Q
Explain the aetiology/risk factors of benign prostatic hyperplasia
A
- UNKNOWN
- Link with hormonal changes (e.g. androgens)
- Risk Factors: reduced risk with soya/vegetable based diets and negative association with cirrhosis
18
Q
Summaries the epidemiology of benign prostatic hyperplasia
A
- COMMON
- 70% of men > 70 yrs have histological BPH (50% of them will experience symptoms)
- More common in the west than the east
- More common in Afro-Caribbeans
19
Q
Recognise the presenting symptoms of benign prostatic hyperplasia
A
• Obstructive Symptoms o Hesitancy o Poor or intermittent stream o Terminal dribbling o Incomplete voiding • Irritative/Storage Symptoms o Frequency o Urgency o Urge incontinence (leakage of urine that accompanies an intense desire to pass water with failure of restraint) o Nocturia • TIP: the obstructive and irritative symptoms can be remembered using the mnemonic FUND HIPS o Frequency o Urgency o Nocturia o Dysuria o Hesitancy o Incomplete voiding o Poor stream o Smell/odour • Acute Retention Symptoms o Sudden inability to pass urine o Associated with SEVERE PAIN • Chronic Retention Symptoms o Painless o Frequency - with passage of small volumes of urine o Nocturia is a major feature
20
Q
Recognise the signs of benign prostatic hyperplasia on physical examination
A
• DRE - the prostate is usually smoothly enlarged with a palpable midline groove
• NOTE: there is poor correlation between the size and the severity of the symptoms
• Signs of Acute Retention
o Suprapubic pain
o Distended, palpable bladder
• Signs of Chronic Retention
o A large distended painless bladder (volume > 1 L)
o Signs of renal failure
21
Q
Identify appropriate investigations for benign prostatic hyperplasia
A
• Urinalysis
o Check for UTI signs and blood
• Bloods
o U&Es - check for impaired renal function
o PSA
• Midstream Urine
o MC&S
• Imaging
o US of urinary tract (check for hydronephrosis)
o Bladder scanning to measure pre- and postvoiding volumes
o Transrectal Ultrasound Scan (TRUS) - allows assessment of bladder size and volume
o Flexible Cystoscopy
22
Q
Generate a management plan for benign prostatic hyperplasia
A
• In Emergency (acute urinary retention) o Catheterisation • Conservative (if mild) o Watchful waiting • Medical o Selective a-blockers (e.g. tamsulosin) relax the smooth muscle of the internal urinary sphincter and prostate capsule o 5a-reductase inhibitors (e.g. finasteride) will inhibit the conversion of testosterone to dihydrotestosterone, which can reduce prostate size by around 20% • Surgery o TURP o Open prostatectomy
23
Q
Identify 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 • Complications of TURP o Retrograde ejaculation (you ejaculate up into your bladder because the internal urinary sphincter is relaxed) o Haemorrhage o Incontinence o TURP syndrome • DEFINITION: seizures or cardiovascular collapse caused by hypervolaemia and hyponatraemia due to absorption of glycine irrigation fluid o Urinary infection o Erectile dysfunction o Urethral stricture
24
Q
Summarise the prognosis for patients with benign prostatic hyperplasia
A
- Mild symptoms are usually well controlled medically
* Most patients get significant relief from surgery
25
Define bladder cancer
• Malignancy of bladder cells
o Most bladder cancers are transitional cell carcinomas
o RARELY, bladder cancers may be squamous cell carcinomas associated with chronic inflammation (e.g. schistosomiasis)
26
Explain the aetiology / risk factors of bladder cancer
```
• UNKNOWN
• Risk Factors
o Smoking
o Dye stuffs (naphthylamines and benzidine)
o Cyclophosphamide treatment
o Pelvic irradiation
o Chronic UTIs
o Schistosomiasis
```
27
Summarise the epidemiology of bladder cancer
* 2% of cancers
* 2nd most common cancer of the genitourinary tract
* 2-3 x more common in MALES
* Peak incidence: 50-70 yrs
28
Recognise the presenting symptoms of bladder cancer
```
• Painless macroscopic haematuria
• Irritative/storage symptoms
o Frequency
o Urgency
o Nocturia
• Recurrent UTIs
• Rarely: ureteral obstruction
```
29
Recognise the signs of bladder cancer on physical examination
* Often NO SIGNS
| * Bimanual examination may be performed as part of disease staging
30
Identify appropriate investigations for bladder cancer and interpret the results
* Cystoscopy - allows visualisation, biopsy or removal
* Ultrasound
* Intravenous urography
* CT/MRI for staging
31
Define chronic kidney disease (CKD)
• Progressive loss of kidney function over a period of months or years
• The definition is based on the presence of kidney damage or decreased kidney function (i.e. eGFR < 60 ml/min per 1.73 m2) for three months or more
• Classification of CKD
o Stage 1: Normal
• eGFR > 90 ml/min per 1.73 m2 with other evidence of CKD (microalbuminuria, proteinuria, haematuria, structural abnormalities, biopsy showing glomerulonephritis)
o Stage 2: Mild Impairment
• eGFR 60-89 ml/min per 1.73 m2 with other evidence of CKD
o Stage 3a: Moderate Impairment
• eGFR 45-59 ml/min per 1.73 m2
o Stage 3b: Moderate Impairment
• eGFR 30-44 ml/min per 1.73 m2
o Stage 4: Severe Impairment
• eGFR 15-29 ml/min per 1.73 m2
o Stage 5: Established Renal Failure
• eGFR < 15 ml/min per 1.73 m2 or on dialysis
32
Explain the aetiology/risk factors of CKD
```
• In developed countries it is mainly associated with:
o Age
o Diabetes mellitus
o Hypertension
o Obesity
o Cardiovascular disease
• Other risk factors:
o Arteriopathic renal disease
o Nephropathies
o Family history
o Neoplasia
o Myeloma
o Systemic disease (e.g. SLE)
o Smoking
o Chronic use of NSAIDs
```
33
Summarise the epidemiology of CKD
* COMMON
* Risk increases with age
* Often associated with other diseases (e.g. cardiovascular disease)
34
Recognise the presenting symptoms of CKD
```
• Often ASYMPTOMATIC
• May be an incidental finding of a routine blood or urine test
• Symptoms of Severe CKD:
o Anorexia
o Nausea and vomiting
o Fatigue
o Pruritus
o Peripheral oedema
o Muscle cramps
o Pulmonary oedema
• Sexual dysfunction is common
```
35
Recognise the signs of CKD on physical examination
• Physical examination rarely reveals many clues
• May show signs of underlying disease (e.g. SLE)
• May show complications of CKD (e.g. anaemia)
• Signs of CKD:
o Skin pigmentation
o Excoriation marks
o Pallor
o Hypertension
o Peripheral oedema
o Peripheral vascular disease
36
Identify appropriate investigations for CKD
• Assessment of Renal Function
o Urea - not ideal because it varies massively depending on hydration status and diet
o Creatinine - useful but has limitations. Renal function can drop considerably with minimal change in serum creatinine
o Isotopic GFR - GOLD STANDARD but expensive
• Biochemistry
o Glucose - check for undiagnosed diabetes and diabetic control
o Potassium - raised
o Also check sodium, bicarbonate, calcium, phosphate
• Serology
o Antibodies
• ANA - SLE
• c-ANCA - granulomatosis with polyangiitis (Wegener's)
• Anti-GBM - Goodpasture's syndrome
o Hepatitis serology
o HIV serology
• Urinalysis
o Check for proteinuria/haematuria
o 24 hr urine collection
o Serum or urine protein electrophoresis - check for multiple myeloma
• Imaging
o Ultrasound - check for structural abnormalities
o CT/MRI
o X-Ray KUB - check for stones
• Renal Biopsy
37
Define epididymitis and orchitis
• Inflammation of the epididymis or testes
o 60% of epididymitis is associated with orchitis
o Most cases of orchitis are associated with epididymitis
38
Explain the aetiology/risk factors of epididymitis and orchitis
```
• Most cases are INFECTIVE in origin
• Bacterial
o If < 35 yrs: Chlamydia and Gonococcus
o If > 35 yrs: mainly coliforms (e.g. Enterobacter, Klebsiella)
o RARE: TB, syphilis
• Viral
o Mumps
• Fungal
o Candida if immunocompromised
• 1/3 are IDIOPATHIC
• Risk Factors
o Diabetes
o Rare: vasculitis (e.g. Henoch-Schonlein purpura)
```
39
Summarise the epidemiology of epididmytis and orchitis
* COMMON
* Affects all age groups
* Most commonly: 20-30 yrs
40
Recognise the presenting symptoms of epididymitis and orchitis
* Painful, swollen and tender testis or epididymis
* NOTE: less acute onset than testicular torsion
* Penile discharge
* IMPORTANT: ask about sexual history
41
Recognise the signs of epididymitis and orchitis on physical examination
* Swollen and tender epididymis or testis
* Scrotum may be erythematous and oedematous
* Pyrexia
* Walking will be painful
* Eliciting a cremasteric reflex may be painful
42
Identify appropriate investigations for epididymitis and orchitis
```
• Urine
o Dipstick
o Early morning urine collections for MC&S
• Bloods
o FBC - high WCC
o High CRP
o U&Es
• Imaging
o Increased blood flow on duplex examination
```
43
Generate a management plan for epididymitis and orchitis
```
• Medical
o Antibiotics
• Surgical
o Exploration of testicles if testicular torsion cannot be excluded clinically
o Required if an abscess develops
```
44
Identify possible complications of epididymitis and orchitis
* Pain
* Abscess
* Fournier's gangrene (if the infection is left untreated and spreads)
* Mumps orchitis could cause testicular atrophy and fertility issues
45
Summarise the prognosis for patients with epididymitis and orchitis
* GOOD if treated
| * May take up to 2 months for the swelling to resolve
46
Define glomerulonephritis
• An immunologically mediated inflammation of the renal glomeruli
47
Explain the aetiology / risk factors of glomerulonephritis
• There are loads of different types of glomerulonephritis with different aetiologies
• Some types are caused by the deposition of antigen-antibody complexes in the glomeruli
• This leads to inflammation and activation of complement and coagulation cascades
• The immune complexes may form within the glomerulus (more common) or be deposited from the circulation
• The antigens to which the antibodies are produced are UNKNOWN but may be associated with:
o Bacteria (e.g. Streptococcus viridans, Staphylococci)
o Viruses (e.g. HBV, HCB, measles, mumps, EBV)
o Protozoal (e.g. Plasmodium malariae, schistosomiasis)
o Inflammatory/Systemic diseases (e.g. SLE, vasculitis, cryoglobulinaemia)
o Drugs (e.g. gold, penicillinamine)
o Tumour
• Classification is based on the site of nephron pathology and its distribution
o Minimal-change Glomerulonephritis
• Light microscopy - minimal change
• Electron microscopy - loss of epithelial foot process
o Membranous Glomerulonephritis
• Thickening of glomerular basement membrane (GBM) from immune complex deposition
• Associated with Goodpasture's Syndrome
o Membranoproliferative Glomerulonephritis (MPGN)
• Thickening of GBM
• Mesangial cell proliferation and interdeposition
o Focal segmental glomerulosclerosis
• Glomerular scarring
• Associated with HIV
o Focal segmental proliferative glomerulonephritis
• Mesangial and endothelial cell proliferation
• Focal = involvement of some glomeruli
• Segmental = involvement of parts of individual glomeruli
o Diffuse proliferative glomerulonephritis
• Same as above but affects ALL glomeruli
o IgA Nephropathy
• Mesangial cell proliferation
• Mesangial IgA and C3 deposits
o Crescentic Glomerulonephritis
• Crescent formation by macrophages and epithelial cells, which fills up Bowman's space
o Focal Segmental Necrotising Glomerulonephritis
• Peripheral capillary loop necrosis (occurs in granulomatosis with polyangiitis, microscopy polyarteritis and other vasculitides)
• Often evolves into crescentic glomerulonephritis
NOTE: cryoglobulins are immunoglobulins that precipitate in the cold
48
Summarise the epidemiology of glomerulonephritis
• Accounts for 25% of the cases of chronic renal failure
49
Recognise the presenting symptoms of glomerulonephritis
* Haematuria
* Subcutaneous oedema
* Polyuria or oliguria
* History of recent infection
* Symptoms of uraemia or renal failure (acute and chronic)
50
Recognise the signs of glomerulonephritis on physical examination
• Hypertension
• Proteinuria
• Haematuria (especially in IgA nephropathy)
• Renal failure
• Nephrotic syndrome - consists of a TRIAD of:
o Proteinuria > 3.5 g/24 hrs
o Low serum albumin < 24 g/L
o Oedema
o NOTE: due to the hypoalbuminaema, the liver tries to compensate and increases production of lipids, causing hyperlipidaemia
• Nephritic syndrome (TRIAD: hypertension + proteinuria + haematuria)
o Syndrome comprising of signs of nephritis
o Pores in the podocytes are large enough to allow protein AND red blood cells to pass into the urine
o MAIN FEATURE: Haematuria
• This is in contrast to nephrotic syndrome, which is mainly concerned with proteinuria
o There may also be red cell casts in the urine - indicative of glomerular damage
o Other features:
• Proteinuria
• Hypertension
• Low urine output (due to decreased renal function)
o NOTE: in nephrotic syndrome, only PROTEINS are moving into the urine
51
Identify appropriate investigations for glomerulonephritis
```
• Bloods
o FBC
o U&Es + creatinine
o LFTs (check albumin)
o Lipid profile
o Complement studies
o Antibodies:
• ANA
• Anti-dsDNA
• ANCA
• Anti-GBM antibody
• Cryoglobulins
• Urine
o Microscopy - check for red cell casts
o 24 hr collection: creatinine clearance and protein
• Imaging
o Renal tract ultrasound to exclude other pathology (e.g. obstruction)
• Renal Biopsy
o For microscopy
• Investigations for associated conditions (e.g. HBV, HCV and HIV serology)
```
52
Define hydrocoele
• The excessive collection of serous fluid within the tunica vaginalis
53
Explain the aetiology/risk factors of hydrocoeles
```
• Congenital
• Idiopathic
• Tumour
• Infection
• Trauma
• Underlying testicular torsion
• Testicular appendage
• Risk Factors/Associations
o Indirect inguinal hernias in children
o Epididymo-orchitis
o Filariasis (in countries of high prevalence)
```
54
Summarise the epidemiology of hydrocoeles
* VERY COMMON in CHILDREN in the first year of life
| * Common in older men
55
Recognise the presenting symptoms of hydrocoeles
* Scrotal swelling
* Usually ASYMPTOMATIC
* Patients may complain of pain or urinary symptoms due to the underlying cause
56
Recognise the signs of hydrocoeles on physical examination
* Scrotal swelling
* It is possible to get above the swelling
* Transilluminates
* Difficult to separate the swelling from the testicle
57
Identify appropriate investigations for hydrocoeles
```
• Ultrasound - exclude tumour
• Urine - dipstick and MSU for infection
• Blood - markers of testicular tumours:
o a-fetoprotein
o b-HCG
o Lactate dehydrogenase
```
58
Define nephrotic syndrome
• Nephrotic syndrome is characterised by a triad of:
o Proteinuria (> 3 g/24 hr)
o Hypoalbuminaemia (< 30 g/L)
o Oedema
o Hypercholesterolaemia is also a common feature
59
Explain the aetiology / risk factors of nephrotic syndrome
• Most commonly caused by: minimal change glomerulonephritis in children
• However, ALL forms of glomerulonephritis can cause nephrotic syndrome
• Other causes:
o Diabetes mellitus
o Sickle cell disease
o Amyloidosis
o Malignancies (lung and GI adenocarcinomas)
o Drugs (e.g. NSAIDs)
o Alport's syndrome
o HIV
60
Summarise the epidemiology of nephrotic syndrome
• 90% of nephrotic syndrome in CHILDREN is due to minimal change glomerulonephritis
• Most common cause of nephrotic syndrome in ADULTS:
o Diabetes mellitus
o Membranous glomerulonephritis
61
Recognise the presenting symptoms of nephrotic syndrome
* Family history of atopy (in those with minimal change glomerulonephritis)
* Family history of renal disease
* Swelling of face, abdomen, limbs, genitalia (due to hypoalbuminaemia)
* Symptoms of the underlying cause (e.g. SLE)
* Symptoms of complications
62
Recognise the signs of nephrotic syndrome on physical examination
* Oedema: periorbital, peripheral, genital
| * Ascites: fluid thrill, shifting dullness
63
Identify appropriate investigations for nephrotic syndrome
• Bloods
o FBC
o U&E
o LFTs (low albumin)
o ESR/CRP
o Glucose
o Lipid profile (check for secondary hyperlipidaemia)
o Immunoglobulins
o Complement
• Tests to identify the cause
o SLE - ANA, anti-dsDNA antibodies
o Infections:
• Group A -haemolytic streptococcal infection (ASO titre)
• HBV infection (serology)
• Plasmodium malariae (blood film)
o Goodpasture's Syndrome - anti-glomerular basement antibodies
o Vasculitides - polyangiitis with granulomatosis, microscopic polyarteritis (check ANCA)
• Urine
o Urinalysis (check protein and blood)
o MC&S
o 24 hr collection (calculate creatinine clearance and 24 hr protein excretion)
• Renal Ultrasound
o Exclude other causes (e.g. reflux nephropathy)
• Renal Biopsy
• Other imaging: Doppler ultrasound, renal angiogram, CT or MRI (if renal vein thrombosis suspected)
64
Define polycystic kidney disease
• 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 cardiovascular) abnormalities
65
Explain the aetiology / risk factors of polycystic kidney disease
• 85% caused by mutations in PKD1 on chromosome 16
o This is a membrane-bound multidomain protein involved in cell-cell and cell-matrix interactions
• 15% caused by mutations of PKD2 on chromosome 4
• Pathophysiology
o Proliferative/hyperplastic abnormality of the tubular epithelium
o Early on, the cysts are connected to the tubules from which they arise and the fluid content is glomerular filtrate
o When cyst diameter >2 mm, they detach from the tubule and the fluid content is derived from secretion of the lining epithelium
o With time, the cysts enlarge and cause progressive damage to adjacent functioning nephrons
66
Summarise the epidemiology of polycystic kidney disease
* MOST COMMON inherited kidney disorder
| * Responsible for 10% of end-stage renal failure
67
Recognise the presenting symptoms of polycystic kidney disease
* Present at 30-40 yrs
* 20% have no family history
* May be asymptomatic
* Flank Pain - may result from cyst enlargement/bleeding, stone, blood clot migration, infection
* Haematuria
* Hypertension
* Associated with berry aneurysms and may present with subarachnoid haemorrhage
68
Recognise the signs of polycystic kidney disease on physical examination
* Abdominal distension
* Enlarged cystic kidneys
* Palpable liver
* Hypertension
* Signs of chronic renal failure (at late stage)
* Signs of associated AAA or aortic valve disease
69
Identify appropriate investigations for polycystic kidney disease
• US or CT
o Will show multiple cysts bilaterally in enlarged kidneys
o Liver cysts may also be seen
70
Define prostate cancer
• Primary malignant neoplasm of the prostate gland
71
Explain the aetiology/risk factors of pancreatic cancer
```
• UNKNOWN
• Risk Factors
o Age
o Afro-Caribbean
o Family history
o Dietary factors
o Occupational exposure to cadmium
```
72
Summarise the epidemiology of prostate cancer
* COMMON
| * 2nd most common cause of male cancer deaths
73
Recognise the presenting symptoms of prostate cancer
```
• Often ASYMPTOMATIC
• Lower Urinary Tract Obstruction
o Frequency
o Hesitancy
o Poor stream
o Terminal dribbling
o Nocturia
• Metastatic Spread
o Bone pain
o Cord compression
o Systemic symptoms: malaise, anorexia, weight loss
o Paraneoplastic syndromes (e.g. hypercalcaemia)
```
74
Recognise the signs of prostate cancer on physical examination
* Asymmetrical hard nodular prostate
| * Loss of midline sulcus
75
Identify appropriate investigations for prostate cancer
• Bloods
o FBC
o U&Es
o PSA
• NOTE: not a very specific test for prostate cancer
o Acid phosphatase
o LFTs
o Bone profile
• CT/MRI Scan
o Assesses extent of local invasion and lymph node involvement
• Transrectal Ultrasound and Needle Biopsy
• Isotope Bone Scan - check for bone metastases
76
Define renal artery stenosis
• Stenosis of the renal artery
77
Explain the aetiology / risk factors of renal artery stenosis
• Atherosclerosis (older patients) - widespread aortic disease involving the renal artery ostia
• Fibromuscular Dysplasia (younger patients)
o Unknown aetiology
o May be associated with collagen disorders, neurofibromatosis and Takayasu's arteritis
o May be associated with micro-aneurysms in the mid and distal renal arteries (resembling a string of beads on angiography)
• Pathogenesis/Pathophysiology
o Renal hypoperfusion (due to the stenosis) stimulates the renin-angiotensin system leading to increased angiotensin II and increased aldosterone
o This leads to increased blood pressure
o The high blood pressure leads to fibrosis, glomerulosclerosis and renal failure
78
Summarise the epidemiology of renal artery stenosis
* Prevalence unknown
* Accounts for 1-5% of all hypertension
* Fibromuscular dysplasia occurs mainly in women with hypertension < 45 yrs
79
Recognise the presenting symptoms of renal artery stenosis
* History of hypertension in < 50 yrs
* Hypertension refractory to treatment
* Accelerated hypertension and renal deterioration on starting ACE inhibitors
* History of flash pulmonary oedema
* IMPORTANT: ACE INHIBITORS ARE BAD IN RENAL ARTERY STENOSIS
80
Recognise the signs of renal artery stenosis on physical examination
* Hypertension
* Signs of renal failure in advanced bilateral disease
* Renal artery bruits
81
Identify appropriate investigations for renal artery stenosis
• Non-Invasive
o Duplex ultrasound
o Ultrasound measurement of kidney size
• CT Angiogram or MR Angiography: risk of contrast nephrotoxicity
• Digital Subtraction Angiography = GOLD STANDARD
• Renal Scintigraphy
o Uses radio-agent that is either excreted by glomerular filtration or by the tubules
o Addition of an ACE inhibitor causes delayed clearance by the affected kidney (may not be useful in bilateral renal artery stenosis)
82
Define renal cell carcinoma
• Primary malignancy of the kidneys
83
Explain the aetiology / risk factors of renal cell carcinoma
• Renal clear cell carcinoma (80%) - UNKNOWN CAUSE
• Papillary carcinoma (10%) - UNKNOWN CAUSE
• Transitional cell carcinoma (10%)
o NOTE: these occur at the renal pelvis
• Risk Factors
o Associated with certain inherited conditions:
• von Hippel-Lindau disease
Mutation in the von Hippel-Lindau protein, which causes headaches, balance issues, dizziness, limb weakness, vision problems and high blood pressure
• Tuberous sclerosis
A rare genetic disease that causes benign tumours to grow in the brain and other organs (e.g. skin, kidneys, lungs, eyes)
• Polycystic kidney disease
• Familial renal cell cancer
• Smoking
• Chronic dialysis
o NOTE: renal cell cancer can cause abnormal LFTs in the absence of liver metastases = Strauffer's Syndrome
84
Summarise the epidemiology of renal cell carcinoma
* UNCOMMON
* 3% of all adult malignancies
* Peak incidence: 40-60 yrs
85
Recognise the presenting symptoms of renal cell carcinoma
```
• Renal Cell Carcinoma
o Usually present LATE
o Asymptomatic in 90%
o Triad of Symptoms:
• Haematuria
• Flank pain
• Abdominal mass
• Transitional Cell Carcinoma
o Presents EARLIER with haematuria
• Systemic Signs of Malignancy
o Weight loss
o Malaise
o Paraneoplastic syndromes (e.g. fever, hypercalcaemia, polycythaemia)
```
86
Recognise the signs of renal cell carcinoma on physical examination
* Palpable renal mass
* Hypertension
* Plethora
* Anaemia
* A left-sided tumour can obstruct the left testicular vein as it joins the left renal vein, and cause a left-sided varicocoele
87
Identify appropriate investigations for renal cell carcinoma and interpret the results
```
• Urinalysis
o Haematuria
o Cytology
• Bloods
o FBC
o U&Es
o Calcium
o LFTs
o High ESR (in 75%)
• Abdominal Ultrasound
```
```
o Best first-line investigation
o Can distinguish between solid masses and cystic structures
• CT/MRI
o Useful for staging
• Staging system: Robson Staging
```
88
Define testicular cancer
• Malignant tumour of the testes
• Types:
o Seminomas - 50%
o Non-seminomatous germ-cell tumours and teratomas - 30%
o RARE: gonadal stromal tumours (Sertoli and Leydig cell tumours) and non-Hodgkin's lymphoma
89
Explain the aetiology / risk factors of testicular cancer
```
• UNKNOWN
• Risk Factors
o Maldescended testes
o Ectopic testes
o Atrophic tests
```
90
Summarise the epidemiology of testicular cancer
* UNCOMMON
* 1% of male malignancies
* Common age of onset: 18-35 yrs
91
Recognise the presenting symptoms of testicular cancer
* Swelling or discomfort of the testes
* Backache due to para-aortic lymph node enlargement
* Lung metastases --> SOB, haemoptysis
92
Recognise the signs of testicular cancer on physical examination
* Painless, hard testicular mass
* There may be a secondary hydrocoele
* Lymphadenopathy (e.g. supraclavicular, para-aortic)
* Gynaecomastia (tumour produces hCG)
93
Identify appropriate investigations for testicular cancer and interpret the results
```
• Bloods
o FBC
o U&Es
o LFTs
o Tumour Markers
• a-fetoprotein
• b-hCG
• LDH
• Urine Pregnancy Test - will be positive if the tumour produces -hCG
• CXR - show lung metastases
• Testicular Ultrasound
o Allows visualisation of the tumour
o Can see associated hydrocoele
• CT Abdomen and Thorax - allows staging
o Staging System: Royal Marsden Hospital Staging
```
94
Define testicular torsion
• A SURGICAL EMERGENCY. 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 corrected.
95
Explain the aetiology/risk factors of testicular torsion
• Intravaginal (MOST COMMON)
o The spermatic cord twists within the tunica vaginalis
• Extravaginal (usually in neonates)
o The entire testis and tunica vaginalis twist in a vertical axis on the spermatic cord
o Due to incomplete fixation of the gubernaculum to the scrotal wall allowing free rotation
• Risk Factors
o Imperfectly descended testes
o High investment of the tunica vaginalis
96
Summarise the epidemiology of testicular torsion
• Most common cause of acute scrotal pain in 10-18 yr olds
97
Recognise the presenting symptoms of testicular torsion
* Sudden-onset severe hemiscrotal pain
* Abdominal pain
* Nausea and vomiting
98
Recognise the signs of testicular torsion on physical examination
• Swollen, erythematous scrotum on the affected side
• Swollen testicle will lie slightly higher than the unaffected one
• Testicle might lie horizontal
• Thickened cord
• Testicular Appendix
o There may be a visible necrotic lesion on transillumination
• Differential Diagnosis
o Epididymo-orchitis
o Incarcerated inguinal hernia
99
Identify appropriate investigations for testicular torsion
```
• Doppler/Duplex Imaging of the Testes
o Do NOT delay surgery
o Arterial inflow
• REDUCED in testicular torsion
• INCREASED in epididymo-orchitis
```
100
Generate a management plan for testicular torsion
* Exploration of the scrotum within 6 hrs of onset of symptoms
* After the testicle is twisted back into place, a bilateral orchidopexy is performed
* This involves suturing the testicle to the scrotal tissue to prevent recurrence
* If the testicle is necrotic, orchidectomy may be performed
101
Identify possible complications of testicular torsion
* Testicular infarction
* Testicular atrophy
* Infection
* Impaired fertility (due to production of anti-sperm antibodies)
102
Summarise the prognosis for patients with testicular torsion
* From the onset of torsion, a testicle may only survive 4-6 hrs
* With prompt surgical intervention, most testicles are salvaged
103
Define urinary catheterisation
In urinary catheterization a latex, polyurethane, or silicone tube known as a urinary catheter is inserted into a patient's bladder via the urethra. Catheterization allows the patient's urine to drain freely from the bladder for collection
104
Summarise the indications for urinary catheterisation
Specific reasons a urinary catheter may be used include:
to allow urine to drain if you have an obstruction in the tube that carries urine out of the bladder (urethra) – for example, because of scarring or prostate enlargement
to allow you to urinate if you have bladder weakness or nerve damage that affects your ability to pee
to drain your bladder during childbirth if you have an epidural anaesthetic
to drain your bladder before, during or after some types of surgery
to deliver medication directly into the bladder, such as during chemotherapy for bladder cancer
as a last resort treatment for urinary incontinence when other types of treatment have been unsuccessful
105
Identify the possible complications of urinary catheterisation
The main problems caused by urinary catheters are infections in the urethra, bladder or, less commonly, the kidneys. These types of infection are known as urinary tract infections (UTIs) and usually need to be treated with antibiotics.
You can get a UTI from either short- or long-term catheter use. However, the longer a catheter is used, the greater the risk of infection. This is why it's important that catheters are inserted correctly, maintained properly, and only used for as long as necessary.
Catheters can also sometimes lead to other problems, such as bladder spasms (similar to stomach cramps), leakages, blockages, and damage to the urethra.
106
Define urinary tract calculi
```
• Crystal deposition within the urinary tract. Also known as nephrolithiasis.
• Types of Stone:
o Calcium oxalate - MOST COMMON
o Struvite - quite common
o Urate - 5%
o Cysteine - 2%
```
107
Explain the aetiology/risk factors of urinary tract calculi
```
• Many cases are IDIOPATHIC
• Metabolic Causes
o Hypercalciuria
o Hyperuricaemia
o Hypercystinuria
o Hyperoxaluria
• Infection
o Hyperuricaemia
• Drugs
o Indinavir
• RISK FACTORS:
o Low fluid intake
o Structural urinary tract abnormalities (e.g. horseshoe kidney)
```
108
Summarise the epidemiology of urinary tract calculi
* COMMON
* 2-3% of general population
* 3 x more common in MALES
* Age group affected: 20-50 yrs
* Bladder stones more common in developing countries
* Upper urinary tract stones more common in industrialised countries
109
Recognise the presenting symptoms of urinary tract calculi
* Often ASYMPTOMATIC
* SEVERE loin to groin pain
* Nausea and vomiting
* Urinary urgency, frequency or retention
* Haematuria
110
Recognise the signs of urinary tract calculi on physical examination
* Loin to lower abdominal tenderness
* NO signs of peritonism
* Leaking AAA is the main differential to consider in older men
* Signs of systemic sepsis if there is an obstruction and infection above the stone
111
Identify appropriate investigations for urinary tract calculi
```
• Bloods
o FBC - high WCC if infection
o U&Es - check renal function
o Calcium
o Urate
o Phosphate
• Urine
o Dipstick - haematuria is common
o MC&S
• X-Ray KUB
o 80% of kidney stones are radio-opaque
• Intravenous Urography (IVU)
o Allows visualisation of the kidneys and ureters
• Ultrasound
o May show hydronephrosis and hydroureter
• Non-enhanced Spiral CT
o Can also be used to image stones
• Isotope Radiography
o Used to assess kidney function
```
112
Generate a management plan for urinary tract calculi
• ACUTE PRESENTATION
o Analgesia
o Bed rest
o Fluid replacement
o Urine collection to try and retrieve any stone that has passed
• NOTE: most stones < 5 mm will pass spontaneously
o An obstructed, infected kidney is an EMERGENCY and should be treated as soon as possible to relieve the obstruction (e.g. by placing a percutaneous nephrostomy)
• REMOVAL OF CALCULI
o Urethroscopy
• A scope is passed into the bladder and up the ureter to visualise the stone
• It can then be removed by a basket or broken up with a laser
• If the stone cannot be removed, a JJ stent should be placed to allow urine drainage
o Extracorporeal Shock-Wave Lithotripsy (ESWL)
• Non-invasive
• An electromagnetic shockwave is focused onto the calculus to break it up into smaller fragments that can pass spontaneously
o Percutaneous Nephrolithotomy (PCNL)
• Performed for large, complex stones (e.g. staghorn calculi)
• After making a nephrostomy tract, a nephroscope is inserted, which allows disintegration and removal of stones
• TREATMENT OF CAUSE
o Depends on the cause (e.g. parathyroidectomy if hypercalcaemia due to hyperparathyroidism, allopurinol if hyperuricaemia)
• ADVICE
o Increase oral fluid intake
113
Identify possible complications of urinary tract calculi
```
• Of Stones
o Infection (PYELONEPHRITIS)
o Septicaemia
o Urinary retention
• Of Ureteroscopy
o Perforation
o False passage
• Of Lithotripsy
o Pain
o Haematuria
```
114
Summarise the prognosis for patients with urinary tract calculi
* GOOD
* However, infection of the calculus could lead to irreversible renal scarring
* Recurrence of about 50% over 5 yrs
115
Define urinary tract infection
• The presence of a pure growth of > 105 organisms per mL of fresh MSU
• Sub-Classification
o Lower UTI - affecting the urethra (urethritis), bladder (cystitis) or prostate (prostatitis)
o Upper UTI - affecting the renal pelvis (pyelonephritis)
• NOTE: the laboratory classification mentioned above isn't a complete necessity for the diagnosis of UTI - 1/3 women with symptoms of UTI will have negative MSU
• Other Classification
o Uncomplicated UTI - normal renal tract and function
o Complicated UTI - abnormal renal/genitourinary tract, voiding difficulty/obstruction, reduced renal function, impaired host defences, virulent organism (e.g. S. aureus)
116
Explain the aetiology/risk factors of urinary tract infection
```
• MOST UTIs are caused by Escherichia coli
• Other causative organisms:
o Staphylococcus saprophyticus
o Proteus mirabilis
o Enterococci
• Atypical organisms that can cause UTI (usually in immunocompromised individuals):
o Klebsiella
o Candida albicans
o Pseudomonas aeruginosa
• Risk Factors
o FEMALE
o Sexual intercourse
o Exposure to spermicide
o Pregnancy
o Menopause
o Immunosuppression
o Catheterisation
o Urinary tract obstruction
o Urinary tract malformation
```
117
Summarise the epidemiology of urinary tract infections
* VERY COMMON
* 1-3% of GP consultations
* The majority of women will have a UTI in their lifetime
* MUCH more common in FEMALES
118
Recognise the presenting symptoms of urinary tract infections
```
• Cystitis
o Frequency
o Urgency
o Dysuria
o Haematuria
o Suprapubic pain
• Prostatitis
o Flu-like symptoms
o Low backache
o Few urinary symptoms
o Swollen or tender prostate on PR
• Acute Pyelonephritis
o High fever
o Rigors
o Vomiting
o Loin pain and tenderness
o Oliguria (if AKI)
```
119
Recognise the signs of urinary tract infection on physical examination
* Fever
* Abdominal or loin tenderness
* Foul-smelling urine
* Distended bladder (occasionally)
* Enlarged prostate (if prostatitis)
120
Identify appropriate investigations for urinary tract infection
• Urine Dipstick
o Positive leucocyte esterase and nitrites
• Urine Microscopy
o Presence of leucocytes indicates infection
• Urine Culture
o To exclude diagnosis or if the patient failed to respond to empirical antibiotics
• Ultrasound
o Rule out obstruction
• Bloods
o FBC
o U&Es - check renal function
o CRP
o Blood cultures - if systemically unwell and risk of urosepsis
121
Generate a management plan for urinary tract infection
• Empirical treatment of uncomplicated UTI: TRIMETHOPRIN or NITROFURANTOIN
o Treat for 3-6 days
o NOTE: men with UTI may need a longer course of antibiotics
• Alternative Treatments: Co-amoxiclav or Cefalexin
• Prophylactic antibiotics may be used in certain circumstances (e.g. recurrent cystitis associated with sexual intercourse)
122
Identify possible complications of urinary tract infection
```
• Ascending infection can lead to:
o Pyelonephritis
o Perinephric and intrarenal abscess
o Hydronephrosis or pyonephrosis
o AKI
o Sepsis
• Prostatic involvement (e.g. prostatitis) in men with UTIs is common
```
123
Summarise the prognosis for urinary tract infection
• GOOD prognosis with appropriate treatment
124
Define varicocoele
• DEFINITION: dilated veins of the pampiniform plexus forming a scrotal mass.
125
Explain the aetiology/risk factors of varicocoele
• More common on the LEFT (80-90%) because of:
o The angle at which the left testicular vein meets the left renal vein
o Lack of effective valves between the left testicular vein and left renal vein
o Increased reflux from compression of the renal vein (between the superior mesenteric artery and the aorta)
• Due to venous incompetence (sort of like varicose veins)
126
Summarise the epidemiology of varicocoele
* Unusual in boys under 10 yrs old
* Incidence increases after puberty
* Incidence: 15% in general population
* Associated with infertility
127
Recognise the presenting symptoms of varicocoele
```
• Usually ASYMPATOMATIC
o Only 2-10% have symptoms
• Scrotum feels like a bag of worms
• Scrotal heaviness
• Incidental finding at examination
```
128
Recognise the signs of varicocoele on physical examination
* Patient must be STANDING for examination
* The side of the scrotum with the varicocoele will hang lower
* The swelling may reduce when lying down
* Valsalva manouevre whilst standing will increase dilatation
* Cough impulse
129
Identify appropriate investigations for varicocoele
* Sperm count - done as part of fertility investigation
| * Colour Doppler scan
