Renal & Urology Flashcards
1
Q
What is acute kidney injury?
A
An acute decline in the GFR from baseline, with or without oliguria/anuria
2
Q
What is the aetiology of acute kidney injury?
A
Pre-renal:
- Various causes of reduced renal perfusion such as hypovolaemia, haemorrhage, sepsis, third spacing of fluid (e.g. severe pancreatitis), overdiuresis, heart failure
Intrinsic:
- Acute tubular necrosis, rapidly progressive glomerulonephritis, interstitial nephritis
Post-renal:
- Mechanical obstruction of the outflow tract. Retroperitoneal fibrosis, lymphoma, tumour, prostate hyperplasia, strictures, renal calculi, ascending urinary infection and urinary retention
3
Q
What is the epidemiology of acute kidney injury?
A
- Rate of hospitalisation for kidney disease has increased, particularly amongst adults over 65
4
Q
What are the risk factors for acute kidney injury?
A
- Advanced age
- Underlying renal disease
- Malignant hypertension
- Diabetes mellitus
- Myeloproliferative disorders e.g. multiple myeloma
- Connective tissue disease
- Trauma
- Haemorrhage
- Exposure to nephrotoxins
- Sepsis
- Pancreatitis
- Drug overdose
- Surgery
- Recent vascular intervention
- Excessive fluid loss
- Nephrolithiasis
5
Q
What are the presenting symptoms of acute kidney injury?
A
- Reduced urine production
- Vomiting
- Dizziness
- Orthopnoea
- Paroxysmal nocturnal dyspnoea
- Seizures
- Fever
- Haematuria
- Rash
6
Q
What are the signs of acute kidney injury on examination?
A
- Pulmonary oedema
- Tachycardia
- Orthostatic hypotension
- Hypertension
- Peripheral oedema
- Muscle tenderness
- Limb ischaemia
- Prostatic obstructive symptoms
- Arthralgia/arthritis
- Altered mental status
- Signs of uraemia
7
Q
What are the investigations for acute kidney injury?
A
- Basal metabolic profile (including urea & creatinine): Acutely elevated serum creatinine, high serum potassium, metabolic acidosis
- Ratio of serum urea to creatinine: 20:1 or higher supports pre-renal azotaemia
- Urinalysis: RBCs, WBCs, cellular casts, proteinuria, bacteria, positive nitrite and leukocyte esterase
- Urine culture: Bacterial or fungal growth may occur
- FBC: anaemia, leukocytosis, thrombocytopenia
- Renal US: Dilated renal calcyces
- CXR: pulmonary oedema, cardiomegaly
- ECG: Peak T waves, increased PR interval, widened WRS, atrial arrest and deterioration to a sine wave pattern (if severe hyperkalaemia)
8
Q
How is acute renal injury managed?
A
- Volume expansion and/or RBC transfusion
- Vasopressor
- Diuretic
- Renal replacement therapy
9
Q
What are the possible complications of acute renal injury?
A
- Hyperphosphataemia
- Uraemia
- Volume overload
- Hyperkalaemia
- Metabolic acidosis
- Chronic progressive kidney disease
- End-stage renal disease
10
Q
What is the prognosis of acute renal injury?
A
- Variable, depends on cause of injury and severity and duration of AKI
- Up to 6% of patients admitted to ICU have AKI requiring renal replacement therapy (RRT). In hospital, when AKI requires dialysis, mortality exceeds 50%, especially in those with multiorgan failure. Mortality rates are high due to death from underlying disease and complications, not just the AKI.
11
Q
What is benign prostatic hyperplasia?
A
A noncancerous increase in the size of the prostate
- Involves hyperplasia of prostatic stromal and epithelial cells, resulting in the formation of large, fairly discrete nodules in the transition zone of the prostate
12
Q
What is the aetiology of benign prostatic hyperplasia?
A
- Hyperplasia of epithelial and stromal compartments, may be attributed to various factors including shifts in age-related hormonal changes creating androgen/oestrogen imbalances
- Progression from pathological BPH to clinical BPH may require additional factors such as prostatitis, vascular effects and changes in the glandular capsule
13
Q
What is the epidemiology of benign prostatic hyperplasia?
A
Prevalence of histological BPH does increase with age and affects approximately 42% of men between the ages of 51 and 60 years, and 82% of men between the ages of 71 and 80 years.
14
Q
What are the presenting symptoms of benign prostatic hyperplasia?
A
- Presence of risk factors (over 50yrs)
- Storage symptoms: Frequency, urgency, nocturia
- Voiding symptoms: Weak stream, hesitancy, intermittency, straining, incomplete emptying and post-void dribbling
15
Q
What are the signs of benign prostatic hyperplasia on examination?
A
- Bladder enlargement on abdo exam
- Rectum exam: enlarged prostate feels smooth, cannot obtain accurate representation of prostate size
16
Q
What are the investigations for benign prostatic hyperplasia?
A
- MSU, U&Es
- Ultrasounds: large residual volume-?hydronephrosis
- Rule out cancer: transrectal USS, biopsy, PSA
17
Q
How is benign prostatic hyperplasia managed?
A
- Lifestyle: Reassure against prostate cancer, avoid caffeine and alcohol, drink less at night, relax when voiding, voiding twice in a row to aid emptying, control urgency by practicing distracting methods, train bladder to hold on
- Mild to moderate: watchful waiting
- Moderate: alpha blockers (decrease smooth muscle tone of prostate and bladder). Competitive inhibitor of 5a-reductase (finasteride)
- Surgery: when decreased renal function and upper tract dilation
18
Q
What are the possible complications of benign prostatic hyperplasia?
A
Acute retention/retention with overflow
19
Q
What is the prognosis for benign prostatic hyperplasia?
A
The majority of patients with BPH can expect at least moderate improvement of their symptoms with a decreased bother score and improved quality of life. L
20
Q
What is chronic kidney disease?
A
Defined either as kidney damage or GFR of less than 60mL/min/1.73m2 for 3 months
- Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies
21
Q
What is the aetiology of chronic kidney disease?
A
- Diabetes mellitus and hypertension are two most common causes
- Vascular disease: hypertension, renal artery atheroma, vasculitis
- Glomerular disease: Glomerulonephritis, diabetes, amyloid, SLE
- Tubulointerstitial disease: Pyelonephritis/interstitial nephritis, nephrocalcinosis, tuberculosis
- Obstruction and others: Myeloma, HIV nephropathy, scleroderma, gout, renal tumour, inborn errors of metabolism (e.g. Fabry’s disease)
- Congenital/inherited: Polycystic kidney disease, Alport’s syndrome, congenital hypoplasia
22
Q
What is the epidemiology of chronic kidney disease?
A
- Incidence of end stage CKD in England more than 110 per million population per year
- Higher incidence in Asian immigrants than native British population
23
Q
What are the presenting symptoms of chronic kidney disease?
A
- Anorexia, nausea, pruritis
- Later: diarrhoea, drowsiness, convulsions, coma
- Symptoms of cause and other complications
24
Q
What are the signs of chronic kidney disease on examination?
A
- Systemic: Kussmaul’s breathing (acidosis), signs of anaemia, oedema, pigmentation, scratch marks
- Hands: Leuconychia, brown line at distal end of nail
- May be an arteriovenous fistula (buzzing lump in wrist or forearm)
- Signs of complications (e.g. neuropathy, renal bone disease)
25
What are the investigations for chronic kidney disease?
- Blood: FBC (decreased Hb: normochromic, normocytic) U&E (decreased urea and creatinine), eGFR (can be derived from creatinine and age using the MDRD calculator), decreased Ca++. raised phosphate, AlkPhos, PTH
- Investigate for suspected aetiology e.g. ANCA, ANA, glucose
- 24h urine collection: Protein, creatinine clearance (which is rough estimate of GFR)
- Imaging: Signs of osteomalacia & hyperparathyroidism. CXR may show pericardial effusion or pulmonary oedema
- Renal ultrasound: Measure size, exclude obstruction and visualise structure
- Renal biopsy: For changes specific to underlying disease, contraindicated for small kidneys
26
What is epididymitis and orchitis?
Epididymitis: Infection or less frequently, inflammation of epididymis (coiled tube on back of testicle
Orchitis: Inflammation of one or both of the testicles
27
What is the aetiology of epididymitis and orchitis?
- Chlamydia (under 35 yrs)
- E. coli
- Mumps
- N. Gonorrhoea
- TB
- Non-STI (associated with UTI) if over 35 yrs
28
What is the epidemiology of epididymitis and orchitis?
Fifth most common urological diagnosis in men ages 18-50 years
29
What are the presenting symptoms of epididymitis and orchitis?
- Sudden onset tender swelling
- Dysuria
- Sweats/fever
30
What are the signs of epididymitis and orchitis on examination?
- Parotid swelling (RNA paramyxovirus) if Mumps
31
What are the investigations for epididymitis and orchitis?
- First catch urine sample
- Urethral discharge swab -> MC & S
- STI screen
- Warn of possible infertility, Sx getting worse before improvement
32
How is epididymitis and orchitis managed?
- If under 35 yrs, Doxocycline or azithromycin (chlamydia, trachomatis, STI), Rx sexual partners, Cetriaxone is neisseria gonorrheae suspected
- Over 35: Ciprofloxacin
- Analgesia, scrotal support, abscess drainage
33
What are the possible complications of epididymitis and orchitis?
- Scrotal abscess and pyocele
- Testicular infarction
- Fertility problems
- Testicular atrophy
34
What is the prognosis of epididymitis and orchitis?
Patients with epididymitis secondary to a sexually transmitted disease have 2-5 times the risk of acquiring and transmitting HIV.
35
What is glomerulonephritis?
Immunologically mediated inflammation of renal glomeruli?
36
What is the aetiology of glomerulonephritis?
Infection: Bacterial (streptococcus viridans, group A B-haemolytic streptococci, staphylococci, gonococci, Salmonella, syphillis) Viral (Hep B/C, HIV, measles, mumps, ECV, VZV, coxsackie) Protozoal (Plasmodium malariae, schistosomiasis, filariasis
- Inflammatory/systemic diseases: SLE, systemic vasculitis, cyroglobulinaemia
- Drugs: Gold, penicillamine
- Tumours: Classified based on site of nephron pathology and its distribution
37
What is the epidemiology of glomerulonephritis?
Makes up to 25% of cases of chronic renal failure
38
What are the presenting symptoms of glomerulonephritis?
- Heamaturia, subcutaneous oedema, polyuria or oliguria, proteinuria. History of recent infection
- Symptoms of uraemia or renal failure (acute and chronic)
39
What are the signs of glomerulonephritis on examination?
- Hypertension
- Proteinuria (less than 3g/24h)
- Haematuria (microscopic or macroscopic, especially IgA nephropathy)
- Nephrotic syndrome (usually for minimal-change glomerulonephritis in children and membranous glomerulonephritis in adults)
- Nephritic syndrome (haematuria, proteinuria, subcutaneous oedema, oliguria, hypertension, uraemia)
- Renal failure (acute or chronic) and
- Partial lipodystrophy (loss of subcutaneous fat in MPGN type II)
40
What are the investigations for glomerulonephritis?
- Blood: FBC, U&E and creatinine, LFT (albumin), lipid profile, complement studies (C3,C4, C3 nephritic factor in MPGN), ANA, anti-double stranded DNA, ANCA, anti-GBM antibody, cyroglobulins if appropriate
- Urine: Microscopy (dysmorphic RBCs, red-cell casts, 24h collection, creatinine clearance, protein
- Imaging: Renal tract ultrasound (to exclude other pathology)
- Renal biopsy: Light microscopy, electron microscopy, immunofluorescence microscopy
- Investigation for associated infections e.g. Hep B, Hep C or HIV serology
41
What is hydrocele?
- Collection of serous fluid between layers of membrane (tunica vaginalis) that surrounds the testis or along the spermatic cord.
- Communicating and non-communicating
- In communicating hydroceles, a patent processus vaginalis connects the peritoneum with the tunica vaginalis, which allows peritoneal fluid to flow freely between both structures
42
What is the aetiology of hydrocele?
- Most paediatric hydroceles are congenital and resolve within the first year of life in the majority of cases
- Most adult hydroceles are acquired
- Non-communicating hydroceles found secondary to minor trauma, infection, testicular torsion, epididymitis, varicele operation or testicular tumour
- Communication hydroceles may occur following icnreased intra-abdominal fluid or pressure (due to shunts, peritoneal dialysis, or ascites) if there is a patent processus vaginalis
- Pts with connective tissue disorders have high risk of communicatin hydroceles
43
What is the epidemiology of hydrocele?
- Predonominantly occur in males, rare in females
| - They are common in male infants and children and in many cases are associated with an indirect inguinal hernia
44
What are the presenting symptoms of hydrocele?
- Presence of risk factors: Male sex, prematurity & low birth weight
- Infants
- Scrotal mass
45
What are the signs of hydrocele on examination?
- Transillumination
- Enlargement of scrotal mass following activity
- Variation in scrotal mass during the day
46
What are the investigations for hydrocele?
- Clinical diagnosis
| - Ultrasound
47
What is nephrotic syndrome?
Characterised by proteinuria (over 3g/24h), hypoalbuminaemia (less than 30g/L), oedema and hypercholesterolaemia
48
What is the aetiology of nephrotic syndrome?
Commonest cause in minimal change in glomerulonephritis in children but all forms of glomerulonephritis can cause nephrotic syndrome
- Other causes: diabetes mellitus, sickle cell disease, amyloidosis, malignancies (lung and GI adenocarcinomas), drugs (NSAIDs), Alport's syndrome, HIV infection
49
What is the epidemiology of nephrotic syndrome?
- Most common cause in children (90%): minimal change glomerulonephritis (usually seen in boys under 5yrs, rare in black populations)
- Most common causes in adults: diabetes mellitus, membranous glomerulonephritis
50
What are 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
- Symptoms of underlying cause (e.g. SLE)
- Symptoms of complications (e.g. renal vein thrombosis: loin pain, haematuria)
51
What are the signs of nephrotic syndrome on examination?
- Oedema: peiorbital, peripheral, genital
| - Ascites: fluid thrill, shifting dullness
52
What is the pathogenesis of nephrotic syndrome?
Structural damage to basement membrane or reduction in negatively charged components within it reduces the filtration of large protein molecules by the glomerulus, causing proteinuria and hypoalbuminaemia
53
What are the investigations for nephrotic syndrome?
- Blood: FBC,U&E, LFT (decreased albumin), ESR/CRP, glucose, lipid profile (secondary hyperlipidaemia, immunoglobulin
54
What are the tests to identify the underlying cause of glomerulonephritis (used for nephrotic syndrome)?
- SLE: ANA, anti-dsDNA
- Infections: Group A B-haemolytic streptococcal infection (ASO titre, HBV infection (serology), plasmodium malariae (blood films)
- Goodpasture's syndrome: Anti-glomerular basement membrane antibodies
- Vasculitides: e.g. Wegener's and microscopies polyarteritis (ANCA)
- Urine: Urinalysis, microscopy
- Renal ultrasound: Excludes other renal disease that may cause proteinureia e.g. reflux nephropathy
- Renal biopsy
- Other imaging: Doppler, renal angiogram
55
What is polycystic kidney disease (PKD)?
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
56
What is the aetiology of polycystic kidney disease?
- 85% are mutations in PKD1 on chromosome 16, a membrane bound multidomain protein involved in cell-cell and cell-matrix interactions: 15% are mutations in PKD2 on chromosome 4, a Ca++ permeable cation channel
- Pathological process is considered to be a proliferative/hyperplastic abnormality of the tubular epithelium. In early stages, cysts are connected to the tubules from which they arise and the fluid content is glomerular filtrate. When cyst diameter >2mm, most detach from the patent tubule and fluid content is derived from secretions of the lining epithelium. With time, cysts enlarge and cause progressive damage to adjacent functioning nephrons
57
What is the epidemiology of polycystic kidney disease?
Most commonly inherited kidney disorder, affection 1/800, responsible for nearly 10% of end-stage renal failure in adults
58
What are the presenting symptoms of polycystic kidney disease?
- Usually present at 39-40 years. 20% have no FHx.
- May be asymptomatic
- Pain in flanks as a result of cyst enlargement/bleeding, stone, blood clot migration, infection
- Haematuria (may be gross)
- Hypertension
- Associated with intracranial 'berry' aneurysms and may present with subarachnoid haemorrhage (sudden onset headache)
59
What are the signs of polycystic kidney disease on examination?
- Abdominal distension, enlarged cystic kidneys and liver palpable, hypertension. Signs of chronic renal failure at late stage
- Signs of associated aortic aneurysm or aortic valve disease
60
What are the investigations for polycystic kidney disease?
- Ultrasound or CT imaging: Multiple cysts observed bilaterally in enlarged kidneys, sensitivity of detection poor for those under 20 yrs
- Liver cysts may also be seen
61
What is renal artery stenosis?
Stenosis of the renal artery
62
What is the aetiology of renal artery stenosis?
- Atherosclerosis (older pt): Widespread aortic disease involving renal artery ostia
- Fibromuscular dysplasia (younger patient): Fibromuscular dysplasia is of unknown aetiology but may be associated with collagen disorders, neurofibromatosis and Takayasu's disease. This may be associated with micro-aneurysms in the mid and distal renal arteries (resembling string of beads on angiography)
63
What are the presenting symptoms of renal artery stenosis?
- History of hypertension in under 50 yrs
- Hypertension refractory to treatment
- Accelerated hypertension and renal deterioration on starting ACE inhibitor
- History of flash pulmonary oedema
64
What is the epidemiology of renal artery stenosis?
- Prevalence is unknown but believed to account for 1-5% of all hypertension; fibromuscular dysplasia occurs in mainly women with hypertension at less than 45 yrs
65
What are the signs of renal artery stenosis on examination?
- Hypertension
- Signs of renal failure in advanced bilateral disease
- An abdominal bruit may be heard over the stenosed artery
66
What is the pathogenesis of renal artery stenosis?
Renal hypoperfusion stimulated the renin-angiotensin system leading to increased circulating angiotensin II and aldosterone, increasing BP, which is turn, with time, causes fibrosis, glomerulosclerosis and renal failure
67
What are the investigations for renal artery stenosis?
- Non invasive: Duplex ultrasound (technically difficult if obese. Ultrasound measurement of kidney size (predicts outcome after revascularisation, kidneys less than 8cm unlikely to improve)
- CT angiography or MRA: Often used now, risk of contrast nephrotoxicity
- Digital subtraction angiography: gold standard assessment
- Renal scintigraphy
68
What is testicular torsion?
Urological emergency caused by the twisting of the testicle on the spermatic cord leading to constriction of the vascular supply and time-sensitive ischaemia and/or necrosis of testicular tissue
69
What is the aetiology of testicular torsion?
- Bell clapper deformity of the common anatomical defect association with the development of intra-vaginal testicular torsion
- Trauma
70
What is the epidemiology of testicular torsion?
Affects males of any age but most commonly adolescent boys
71
What are the presenting symptoms testicular torsion?
- Age under 25 yrs
- Neonate
- Testicular pain
- Intermittent or acute on-and-off pain
- No pain relief upon elevation of scrotum
- Nausea and vomiting
- Abdominal pain
72
What are the signs of testicular torsion of examination?
- Bell clapper deformity
- Scrotal swelling or oedema
- Scrotal erythema
- Reactive hydrocele
- High-riding testicle
- Horizontal lie
- Absent cremasteric reflex
73
What are the investigations for testicular torsion?
- Grey scale ultrasound: presence of fluid and whirlpool sign
- Power Doppler ultrasound: absent or decreased blood flow in affected testicle
- Colour Doppler ultrasound
74
How is testicular torsion managed?
- Immediate urological consultation for emergency scrotal exploration
- Supportive care
75
What are the possible complications of testicular torsion?
- Infarction of testicle/permanent testicular damage/loss of testicles
- Infertility secondary to loss of testicle
- Psychological implication of losing a testis
- Cosmetic deformity
- Recurrent torsion
76
What is the prognosis for testicular torsion?
- Longer it takes for diagnosis and repair, greater likelihood that pt will develop tissue necrosis, decrease tissue viability, decreased spermatogenesis and possible infertility
- Recurrent torsion may develop in pts with past history of testicular fixation may years later
77
What is a transurethral resection of the prostate?
Operation used to treat benign prostatic hyperplasia
- Performed by visualising prostate through the urethra and removing tissue by electrocautery or sharp dissection
- Done with spinal or general anaesthetic
78
What are the indications for transurethral resection of the prostate (TURP)?
- Benign prostatic hypertension if not resolved medically
79
What are the possible complications of transurethral resection of the prostate (TURP)?
- Bleeding
- Clot retention and clot colic
- Bladder wall injury such as perforation
- TURP syndrome: Hyponatraemia and water intoxication from the open prostatic sinusoids during the procedure. Can lead to confusion, changes in mental status, nausea, vomiting and even coma
- Urinary incontinence
- Retrograde ejaculation
80
What is urinary catheterisation?
A latex, polyurethane, or silicone tube is inserted into a patient's bladder via the urethra
- Allows patient's urine to drain freely from the bladder for collection
- May be used to inject liquids used for treatment or diagnosis of bladder conditions
81
What are the indications for urinary catheterisation?
- Provide relief of discomfort from bladder distension
- Decompression of bladder
- Measure residual urine
- Management of pts with spinal cord injury, neuromuscular degeneration or incompetent bladders
- Post-surgery and in critically ill pts to monitor urinary output
- Prolonged and chronic urinary retention
82
What are the possible complications of urinary catheterisation?
- UTI
- Allergic reaction to material e.g. latex
- Bladder stones
- Injury to urethra
- Kidney damage
- Infection of urinary tract, kidney or blood (septicaemia)
83
What are urinary tract calculi?
- Stones consist of crystal aggregates
- Stones form in collecting ducts and may be deposited anywhere from renal pelvis to urethra
- Opaque and lucent stones
- Main sites: pelvic ureteric junction, pelvic brim, ureterovesical junction
84
What is the aetiology of urinary tract calculi?
- Idiopathic
- Season: variations in Ca and oxylate levels mediated via vid D synthesis and sunlight
- Dehydration
- UTIs
- Drugs: diuretics antacids, acetazolamide, steroids, theophylline, aspirin, allopurinol, vit C and D, indinavir
- Diet: chocolate, tea, rhubarb, strawberries, nuts, spinach
85
What are the risk factors for urinary tract calculi?
- Recurrent UTIs
- Metabolic abnormalities: hypercalcuria, hypercalcaemia, hyperthyroid, Addison's, Cushing's, vit D excess
- Urinary pH
- Congenital: horseshoe kidneys, hydronephrosis
- Family Hx
- Drugs
- Foreign bodies: stents: catheters
86
What is the epidemiology of urinary tract calculi?
- Male: female 3:1
| - Peak age: 20-40 yrs
87
What are the presenting symptoms of urinary tract calculi?
- Asymptomatic
- Renal colic: Pain, nausea & vomiting, cannot lie still unlike peritonitis
- Renal obstruction: felt in loin, between rib 12 and lateral lumbar muscles
- Obstruction of lower ureter: bladder irritability, pain in scrotum, labia majora pain
- Obstruction of bladder/urethra: pelvic pain, dysuria, frequency and interrupted flow
88
What are the signs of urinary tract calculi on examination?
- Usually no tenderness on examination
| - Renal angle tenderness to percussion if retroperitoneal inflammation
89
What could be the differential diagnosis for urinary tract calculi?
- Peritonitis: but cannot lie still with renal colic
| - Obstruction of mid ureter may mimic appendicitis/ diverticulitis
90
What are the investigations for urinary tract calculi?
- Bloods: FBC, U&Es, calcium, phos, albumin, PTH, vit D, urate, bicarb, serum ACE, thyroid function
- Urine: Dipstick, microscopy, culture, urine pH, 24h collection, random urine, pregnancy test in females of child bearing age
- KUB: plain radiograph, shows radio-opaque stones, opaque ( calcium oxalate), semi-opaque (cysteine), lucent (urate)
- IV urogram: IV contrast may show filling defect in urinary outflow
- High resolution helical CT abdomen: can exclude AA (presents similarly)
- Renal US: first line is pregnancy, assess hydronephrosis, may miss smaller stones, cannot differentiate between stones
- Chemical analysis if stone passed
91
How is urinary tract calculi managed?
- Analgesics: multimodal- weak opioid, NSAIDs, regular paracetamol
- Rehydrate: oral/IV and stones may be passed naturally if under 5mm
- Antibiotics: cef or gentamicin
- Treat UTI/exacerbating factors (cefuroximine/gentamicin)
- Stones more than 5mm in lower ureter should pass with increased fluid intake
92
How should urinary tract calculi more than 5mm with pain not resolving be managed?
- Medical expulsion therapy
- Ureteric spasm: Ca channel antagonists, alpha antagonists
- Extracorporeal shockwave lithotripsy
- Ureteroscopy and basket
- Cystoscopy
- Percutaneous nephrlithomoty
93
What are the possible complications of urinary tract calculi?
- Obstruction and hydronephrosis
- Ureteric stricture
- Intrarenal/perinephric abscess
- Xanthogranulomatous pyelonephritis
- Urine extravasation
- Infection
- Renal failure if primary hyperoxaluria
94
What is the prognosis for urinary tract calculi?
- 20% will not pass spontaneously
| - 50% recurrence in 5 years
95
What is a urinary tract infection?
- Characterised by presence of more than 100,000 of colony-forming units per mililitre of urine.
- UTI's may affect bladder (cystitis), kidney (pyelonephritis) or prostitis (prostatitis)
96
What is the aetiology of urinary tract infections?
- Usually transurethral ascent of normal colonic organisms
- The most common organisms is E.coli, others include Proteus mirabilis, Klebsiella and Enterococci (more common in hospitals)
97
What is the epidemiology of urinary tract infections?
Common in females: 30% of women experience UTI at some point in their lives
- UTI may be seen in 5% of pregnant women, 2% of non-pregnant, 20% of elderly living at home and 50% of institutionalised elderly
- UTI rare in children and young men (if present, suspect an underlying cause)
98
What are the presenting symptoms of urinary tract infections?
- May be clinically silent (asymptomatic bacteruria)
- Cystitis: Frequency, urgency, dysuria, haematuria, suprapubic pain, smelly urine
- Pyelonephritis (acute): Fever, malaise, rigors, loin/flank pain
- Prostatitis: Fever, low back/perineal pain, irritative and obstructive symptoms (e.g. hesitancy, urgency, intermittency, poor stream, dribbling)
- Elderly: Malaise, nocturia, incontinence, confusion
Up to 30% of women with UTI symptoms may not have bacteruria
99
What are the signs of a urinary tract infection on examination?
May be asymptomatic
- Cystitis: Fever, abdominal/suprapubic/loin tenderness, bladder distension
- Pyelonephritis: Fever, loin/flank tenderness
- Prostatitis: Tender, swollen prostate
100
What are the investigations for urinary tract infections?
Mid stream urine for
- Dipstick test: for blood, protein, leucocytes, nitrites (urinary bacteria reduce nitrates to nitrites)
- Microscopy, culture and sensitivity
- If there is sterile pyuria (pus cells with no organisms) consider if this may be partially treated UTI, tuberculosis stones, tumour, interstitial nephritis or renal papillary necrosis
- Imaging: Renal US or IV urogram may be considered in women with frequent UTIs and in children & men
101
How are urinary tract infections managed?
- Cystitis: if symptomatic, consider local microbiological policies, commonly used agents are oral co-trimoxazole, trimethroprim, nitrofurantoin or amoxicillin (in females) and ciprofloxacin (males)
- Pyelonephritis: IV gentamicin, cefuroxime or ciprofloxaxin
- Catheterised patients: Obtain a culture and consider changing catheter. Do not treat unless pt symptomatic as catheters invariably become colonised
- Prophylaxis: High fluid intake. Regular micturation to keep bladder empty. Cranberry based products reduce frequency of recurrence. In some cases, low dose long-term (6-12 months) antibiotics for women with frequent UTIs
- Surgical: Rarely necessary. may be necessary for relief of any obstruction and removal of renal calculi
102
What are the possibly complications of urinary tract infections?
- Renal papillary necrosis (in those with underlying renal disease e.g. diabetes mellitus or stones)
- Renal/perinephric abscess (seen on renal ultrasound)
- Pyonephrosis (pus in palvicalyceal system)
- Gram-negative septicaemia
103
What is the prognosis for urinary tract infections?
- Mostly resolve with treatment
| - Among pregnant women, 20% develop acute pyelonephritis if not treated, however, there is a high relapse rate
104
What is varicocele?
Abnormal dilation of the internal spermatic veins and pampiniform plexus that drains the testis
105
What is the aetiology of varicocele?
- Anatomical features, namely increased hydrostatic pressure in the left renal vein and incompetent or congenitally absent valves, typically implicated as primary cause
- Incompetent valves within the left internal spermatic vein
106
What is the epidemiology of varicocele?
10-15% of men and adolescent boys
107
What are the presenting symptoms of varicocele?
- Presence of risk factors (first degree relative esp. brothers, certain somatometric parameters such as tall/low BMI)
- Age over 12
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What are the signs of varicocele on examination?
- Painless scrotal mass
- Left-sided signs/symptoms
- Small testicle
- Infertility
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What are the investigations for varicocele?
- Scrotal US with colour flow Doppler: presence of varicocele
- Semen analysis: variable, reduced sperm count, impaired sperm motility (less than 50% motile spermatazoa)
- Serum FSH + GnRH stimulation: variable, FSH may be elevated (suggesting testicular dysfunction)
- Serum testosterone: may be low
- DNA fragmentation index (DFI): increased
