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Year 3 diagnosis and management > Renal & Urology > Flashcards

Renal & Urology Flashcards

1
Q

What is pre-renal, renal and post-renal AKI?

A

Pre-renal (40-70%)
• Inadequate perfusion e.g. hypotension (cirrhosis too)

Renal (10-15%)
• Cellular damage e.g. haemolytic uraemic syndrome

Post-renal (10-25%)
• Urinary tract obstruction e.g. prostatic hypertrophy

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2
Q

Symptoms and signs of AKI?

A
  • Oliguria
  • Dehydration
  • Hypertension
  • Palpable bladder or kidney
  • Renal bruit
  • Fluid overload (raised JVP, oedema)
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3
Q

Investigations for AKI? What would you see on CXR, ECG, immunology tests, and USS?

A
  1. Urinalysis - RBCs, WBCs, proteinuria, nitrites, leukocytes
  2. Bloods - creatinine >26 confirms diagnosis (also check hyperkalaemia, leukocytosis etc.)
  • CXR - infection, pulmonary oedema
  • ECG - hyperkalaemia
  • Immunology - anti-dsDNA = SLE, anti-GBM = Goodpasture’s
  • Renal USS - stones
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4
Q

Management of AKI?

A

ABCDE + treat hyperkalaemia (10% calcium gluconate)

  1. If hypovolaemia (most) - IV fluids
  2. If hypervoloaemia - IV furosemide
Treat cause
• Stop nephrotoxic drugs
• ABx
• Catheterise
• Dialysis
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5
Q

What is BPH?

A

Hyperplasia of periurethral (transitional) zone of prostate gland

(unlike peripheral layer in prostate carcinoma)

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6
Q

What are the acute and chronic retention symptoms of BPH?

A

Acute
• Sudden inability to pass urine
• Severe pain

Chronic
• Frequency - small volumes of urine
• Nocturia
• Painless

(signs: distended bladder)

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7
Q

Investigations for BPH?

A
  1. Urinalysis - pyruria
  2. PSA - elevated
  3. International prostate symptom score

• Transrectal Ultrasound Scan (TRUS)

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8
Q

Management of BPH?

A

Acute - urinary retention
• Catheterisation

Chronic

• Asymptomatic - conservative, monitor
• Symptomatic, medical:
1. Tamsulosin (alpha blocker)
2. + Finasteride (5a-reductase inhibitor)

• Symptomatic, surgical:
< 80mg = TURP or TUIP surgery. (transurethral resection/incision)
> 80mg = open prostectomy

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9
Q

Cell type of bladder cancer?

A

90% transitional cell carcinomas

80% confined to bladder mucosa, 20% penetrate muscle

Rarely squamous cell associated with chronic inflammation e.g. schistosomiasis

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10
Q

Grading of bladder cancer for prognosis?

A

Grade 1 - differentiated
Grade 2 - intermediate
Grade 3 - poorly differentiated

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11
Q

Symptoms of bladder cancer?

A
  • Painless macroscopic haematuria
  • Irritative/storage symptoms (frequency, urgency, nocturia, voiding irritability)
  • Recurrent UTIs

(obstruction is rare, often no signs)

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12
Q

Investigations for bladder cancer?

A
  • Urinalysis - haematuria, pyruria
  • Urine cytology
  • Cystoscopy (biopsy) - gold standard
  • USS/CT
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13
Q

What defines chronic kidney disease?

A
  • eGFR < 60
  • eGFR > 60 with impaired renal function

> 3 MONTHS

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14
Q

Describe the stages of CKD

A

Stage 1: Normal
• eGFR > 90 with other evidence of CKD (proteinuria etc.)

Stage 2: Mild impairment
• eGFR 60-89 with other evidence of CKD

Stage 3a: Moderate impairment
• eGFR 45-59

Stage 3b: Moderate impairment
• eGFR 30-44

Stage 4: Severe impairment
• eGFR 15-29

Stage 5: Established renal failure
• eGFR < 15 or on dialysis

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15
Q

Signs of CKD?

A
  • Skin pigmentation
  • Uraemic tinge to skin - yellowish
  • Excoriation marks
  • Purpura
  • Peripheral oedema
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16
Q

Investigations for CKD? Including diagnosis of CKD and cause.

A
  1. Isotopic GFR - gold standard
  • Renal ultrasound
  • Glucose - diabetes
  • Serology - e.g. ANA for SLE
  • Renal biopsy - pathology diagnosis
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17
Q

Relationship between epididymitis and orchitis?

A

Most cases of epididymitis associated with orchitis and vice versa

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18
Q

Most common causes of epididymo-orchitis?

A

Bacterial (overall coliforms)
Children: underlying congenital abnormality
< 35 years : chlamydia and gonococcus
> 35 years : coliforms (enterobacter, klebsiella, e. coli)

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19
Q

Symptoms and signs of epididymo-orchitis?

A
  • Painful, swollen and tender epididymis/testis
  • Penile discharge
  • Dysuria
  • Painful walking
  • Pyrexia
  • Painful cremasteric reflex
  • Erythematous/oedematous
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20
Q

Investigations for epididymo-orchitis?

A

Exclude testicular torsion - emergency

  1. Urethral swab (G- diplococci)
    • Urine dipstick
    • Urine culture
  2. Colour duplex USS - diagnostic, important if possibility of TT
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21
Q

Management for epididymo-orchitis?

A

2-4 weeks ABx
< 35 years - doxycycline for chlamydia, add ceftriaxone if gonorrhoea (treat partners)
> 35 years - ciprofloxacin
• analgesia + scrotal support

Surgical
• Exploration if TT can’t be excluded
• Abscess drainage

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22
Q

What 2 syndromes do glomerulonephritis patients present with?

A

Nephrotic - increase in permeability of glomerulus, loss of PROTEIN
Nephritic - thin glomerular BM with pores that allow protein and BLOOD through (haematuria, proteinuria, HTN)

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23
Q

Primary and secondary causes of nephrotic and nephritic syndrome?

A

Nephrotic
• Primary - minimal change disease
• Secondary - diabetes, hep B/C

Nephritic
• Primary - IgA nephropathy
• Secondary - SLE, vasculitis, anti-GBM, post-strep

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24
Q

Why may hyperlipidaemia be seen in nephrotic syndrome?

A

Hypoalbuminaemia cause liver to compensate and increase lipid production

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25
Who usually presents with minimal change disease and give 2 causes
* Child with nephrotic syndrome | * Causes: Hodgkin's, NSAIDs
26
Investigations for glomerulonephritis?
1. Urinalysis 2. Bloods - elevated creatinine, LFTs, GFR, hyperlipidaemia 3. Renal USS - exclusion 4. Renal biopsy - diagnostic
27
What is a hydrocoele?
Excessive collection of serous fluid within the TUNICA VAGINALIS
28
Signs of hydrocoele?
* Scrotal swelling * Possible to get above it * Transilluminates * Difficult to separate from testicle
29
Investigations for hydrocoele?
Diagnosed clinically, but to exclude tumour: 1. Ultrasound - diagnostic (2. Doppler USS - distinguish from varicocoele and TT)
30
Definition of nephrotic syndrome?
Proteinuria, hypoalbuminuria, oedema and hypercholesterolaemia
31
Cause of nephrotic syndrome?
* 90% in children with minimal change glomerulonephritis | * Adults - DM
32
Signs of nephrotic syndrome?
* Periorbital, peripheral and genital oedema | * Ascites
33
Cause of polycystic kidney disease?
* Autosomal dominant | * PKD1 Chr16 - involved in cell-cell, cell-matrix interactions
34
Renal and extra-renal manifestations of polycystic kidney disease?
* Renal - cysts with glomerular filtrate arise from tubules then detach (fluid content then from secretion of lining) and damage adjacent nephrons * Extra-renal - liver cysts, intra-cranial aneurysm (SAH), mitral valve prolapse, ovarian cysts, diverticular disease
35
Symptoms and signs of polycystic kidney disease?
* Flank pain * Haematuria * Berry aneurysm and SAH presentation possible * Enlarged cystic kidneys * Palpable liver * Signs off AAA or aortic valve disease
36
Investigations for polycystic kidney disease?
1. Renal USS - diagnostic if there is FHx and patient meets result criteria 2. CT if USS is unclear 3. Genetic testing if imaging is inconclusive (PKD1/2)
37
What cell type - prostate cancer?
Adenocarcinoma in peripheral prostate
38
Investigations for prostate cancer?
1. PSA - first line but not specific 2. DRE 3. TRUS-biopsy - gold-standard 4. Isotope bone scan
39
Main causes of renal artery stenosis?
* Atherosclerosis 85% | * Fibromuscular dysplasia 10% (younger patients)
40
Which hypertension meds are particularly bad in renal artery stenosis?
ACEi
41
Presentation of renal artery stenosis?
* History of HTN < 50 yrs * HTN resistant to treatment * Renal bruits * Abdominal / carotid / femoral bruits * Weak leg pulses
42
Investigations for renal artery stenosis?
1. Bloods (high creatinine, low potassium) 2. Duplex USS 3. CT/MR angiogram - risk of contrast nephrotoxicity 4. Digital subtraction renal angiography - gold standard
43
Which cells does renal cell carcinoma arise from?
Proximal renal tubular epithelium
44
What are the histological subtypes of renal cell carcinoma?
1. Clear cell 80% 2. Papillary 10% 3. Transitional cell 10% (renal pelvis)
45
Which inherited conditions increase risk of renal cell carcinoma?
* von Hippel-Lindau disease * Tuberous sclerosis * Polycystic kidney disease
46
What is it called when renal cell cancer causes abnormal LFTs in the absence of liver mets?
Strauffer's syndrome
47
Triad of symptoms of renal cell carcinoma?
* Haematuria * Flank pain * Abdominal mass
48
How can a left-sided tumour cause a left-sided varicocoele?
Obstruction of left testicular vein as it joins the left renal vein
49
Investigations for renal cell carcinoma?
1. Bloods 2. Abdo/pelvic USS 3. CT abdo/pelvis - diagnostic (MRI if contrast contraindicated) • Robson staging
50
Types of testicular cancers?
* Seminoma 50% (age 30-45) * Non-seminomatous germ-cell tumours and teratomas 30% (age 20-35) * Rare: gonadal stromal (sertoli and leydig) and non-Hodgkin's
51
Symptoms and signs of testicular cancer?
* Swelling or discomfort of testes * Backache (para-aortic lymph nodes) * Secondary hydrocoele * Lymphadenopathy * Gynaecomastia
52
Investigations for testicular cancer?
1. Doppler USS - diagnostic 2. CT if not confirmed by 1 3. Markers - beta-hCG, a-fetoprotein, LDH
53
2 types of testicular torsion?
Intravaginal - most common • spermatic cord twists within tunica vaginalis Extravaginal - usually neonates • entire testis and tunica vaginalis twists on spermatic cord
54
Symptoms and signs of TT?
* Sudden onset hemiscrotal pain - one testis * Nause and vomiting * Swollen, erythematous * Swollen testicle is slightly higher * Testicle may lie horizontal * Testicular appendix - may be this visible necrotic lesion on transillumination
55
Investigation for TT?
EMERGENCY EXPLORATION SURGERY (1. Doppler USS) Arterial inflow • Reduced in TT • Increased in epididymo-orchitis
56
Management of TT?
1. Emergency scrotal exploration and repair • morphine and anti-emetic 2. If unavailable, Manual Detorsion * Twisted back into place - bilateral orchidopexy - suture to prevent recurrence * Necrotic - orchidectomy
57
Types of urinary tract calculi (composition)?
* Calcium oxalate - most common * Struvite (magnesium ammonium phosphate) - staghorn, quite common * Urate 5% * Hydroxyapatite 5% * Cysteine 2%
58
Symptoms and signs of urinary tract calculi?
* Severe loin to groin pain * Urinary urgency, frequency or retention * Haematuria * Leaking AAA in older men * Systemic sepsis if infection above stone
59
Investigations for urinary tract calculi?
1. Urinalysis - microhaematuria 2. CT-KUB (non-contrast) - gold standard 3. Renal USS (pregancy test in all women of child bearing age to exclude ectopic - if pregnant, USS first imaging)
60
Management of urinary tract calculi?
95% are < 5mm and self-resolve, if no persistent pain, just drink fluids until it passes Acute • IV/IM or PR diclofenac OR morphine • Ondansetron (anti-emetic) • ABx - Trimethoprim if bacterial (IV cefuroxime/gentamicin if obstruction infection) Removal of calculi - dependent on size or pain not resolving • > 5mm - Tamsulosin (alpha-blocker) or nifedipine (CCB) • > 10mm - extracorporeal shock wave lithotripsy followed by urethroscopy with JJ stent • Consider percutaneous nephrolithotomy (keyhole) - large complex stones e.g. staghorn
61
Which infection is common with urinary tract calculi?
Pyelonephritis
62
What is the difference between an upper and lower UTI?
* Upper - renal pelvis (pyelonephritis) | * Lower - urthera (urethritis), bladder (cystitis) or prostate (prostatis)
63
What causes most UTIs?
E. coli
64
Symptoms of UTI? (cystitis, prostatitis, pyelonephritis)
Cystitis • Frequency, urgency, dysuria • Haematuria • Suprapubic pain Prostatitis • Flu-like • Low backache • Swollen and tender prostate on PR Pyelonephritis • High fever, rigors • Vomiting • Loin pain and tenderness
65
Investigations for UTI?
1. Dipstick urinalysis - leukocytes, nitrites 2. MSU for MC+S (always for male, child, pregnant, immunosuppressed or ill) 3. USS - not responding, recurring
66
Management for UTI?
1. ABx: empirical treatment before MC+S results - presume E.coli • Trimethoprim or nitrofurantoin, 3-5 days • Men may need long course Severe or pyelonephritis (upper UTI) - admit with IV gentamicin, then 7 days co-amoxiclav Recurrent - consider prophylactic ABx
67
What is a varicocoele and which side are they most common on (explaining why)?
Dilated veins of pampiniform plexus More common on the LEFT Where left testicular vein meets left renal vein: • angle • lack of effective valves • increased reflux from compression of LRV between superior mesenteric artery and aorta
68
Symptoms and signs of varicocoele?
* Subfertility * 'Bag of worms' * Scrotum with varicocoele hangs lower, whens standing * Swelling may reduce when lying * Valsalva manouevre whilst standing increases dilatation Incidence increases after puberty
69
Investigations for varicocoele?
Clinical diagnosis 1. Colour doppler USS 2. Semen analysis (reduced sperm count)

Year 3 diagnosis and management (9 decks)

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