Renal & Urology Flashcards
What is the function of the urinary tract?
To collect urine produced continuously by the kidneys and store it until an appropriate time to release it
Where are the kidneys?
They are retroperitoneal between T11 and L3 their blood supply is the renal arteries which come directly off the aorta at L1 level
how long are the ureters?
25-30cm
What is the path of the ureters?
they run retroperitoneally, over the Psoas muscle and cross the iliac vessels at the pelvic brim to enter the bladder
How is one way movement down the ureter done?
Peristaltic movements direct the urin down and there is the vesicoureteric junction in the bladder that stops the urine going back up to the kidneys
Which nerves are involved inthe bladder and sphincters?
pelvic nerve parasympathetic S2-S4 which is incoluntary, sympathetic nerves hypogastric plexus T11-L2, involuntary. there is somatic nerve the pudendal nerve S2-4 Onuf’s nucleus ant afferent pelvic nerve wich is sensory and
What are the neural controls involved with urinating?
Cortex: voluntary control, Pontine micturation centre and periaqueductal grey; co-ordination of voiding Sacral micturition centre: micutration reflex and Onuf’s nucleus: the guarding reflex
What are the Guarding reflex and micturation reflex?
Guarding to stop innapropriate voiding and micturation is to allow voiding at an appropriate time
When bladder is in storage phase what is happening?
Bladder fills continuously as urine is produced. As the bladder fills it does receptive relaxation to allow proper filling of the bladder.
What happens as the bladder fills more?
afferent pelvic nerves send slow firing signals to the spinal cord and the sympathetic nerves of the hypogastric plexusu stimulate the relaxation of the detrusor and somatic pudendal nerves contracts theurethral sphincter
What happens during voiding of the bladder?
It is an autonomic spinal reflex. The afferent pelvic nerve sends fast signals to the sacral micturation centre and the pelvic paraympathetic nerve stimulates the detrusor to contract and the pudendal nerve isinhibited to relas the external sphincter
What is the Guarding reflex?
Voluntary control of micturation can occur in anatomically and functionally normal adults,the symathetic nervs stimulates detrussor torelax and pudendal nerve stiumulation results in contraction of the external urethral sphincter.
What symptoms are included in lower urinary tract problems?
Urinating frequently, urination at night, Urgency with or without incontincence. Voiding symptoms hesitanc straining poor or intermittent stream and incomplete emptying, dribbling and blood in the uring and no urine
What is BPH?
Benign prostatic hyperplasioa form histological finding
What is BPE?
Penigne prostatic enlargment from digiral rectal examination
What is BOO?
Bladder outlow obstruction, proven by a test
What is LUTS?
Lower urinary tract symptoms, a constellation of symptoms that are not gender or disease specific
How common is Benign prostatic hypertrophy?
82% men 71-80have it
What is benign prostatic hypertrophy/
Increase in epithelial and stromal cell numbers in the paraurethral area of the prostate can be due to increase in cell number or reduction in cell death
What is benign prostatic obstruction?
Dynamic component, alpha1 adrenoreceptor mediated prostatic smooth muscel contraction often from hyperplasia Static component is the increase in volume effect
What is the role of androgens in benign prostatic hyperplasia?
They faciitate it, castration prior puberty or hypogonadism stop BPH from happening
What is involved in a urology history?
What symptoms, storage, voiding problems are, Duration of symptoms, PMH PSH, Drug history Allergies, Symptom scoring
What is international prostate symptom score?
A table used to evaluates prostate sympyoms
What is involved in urology examination?
General exam, abdominal examination, External genitalia, digital rectal examination, focussed neurological examination, urinalysis
What are investigations for urinary problems?
Real biochemistry, Imaging prostate specific antigen, Flow rates and residual volume, frequency and volume chart, TRUSS transrectal utrasound scan, flexible cytoscopy if infections stones haematureia and urodynamics
What are normal flow rates for urine?
Around 21ml/s to 13ml/s for later
What is normal residual volue?
12 ml
What are complications of Benign prostatic enlargment?
Symptom progression, infections, stones, haematuria, Acute retention, chronic retention, Interactive ostructive uropathy
What happens with Acute retention of urine and treatments?
Painful, normally 600ml-1L normal U&E, pain relived by catheterisation, alphablockers can ave a role in it
What are the complications of urinary retention?
Incomplete bladder emptying, increased risk of infections and stones cna be low pressure if detrusor fails or high if it is obstructive
What kind of treatments are involved with urinary retention?
Appha adrenergic antagonists to improve flow, 5alpha reductase inhibitors to slow hyperplasia, and anticholinergics for overactivity
What are the indications for urinary surgery?
RUSHES Retention UTI's Stones Haematuria Elevated creatinine due to BOO Symptom deterioration
What surgeries are done in urology?
Bladder neck incision, Transurethral resection of prostate, Bipolar, Greenlight laser thullium laser homium enucleation millisretropubicprostatectomy
What are alpha blockers good for?
Symptom reduction but not disease modification
What are the complications of transurethral resection surgery.
sepsis Haemorrhage clot retention
Late- Retrograde ejaculation, erectile dysfunction, urethral stricture, bladder neck stenosis and urinary incontinence
What is a neuropathic bladder?
Dysfunctional bladder due to damage to innervation. There are a range of conditions and knowing the site of lesion can indicate problems
What are the principles of management of neuropathic bladder?
Protect upper urinary tract, improve quality of life, achieve continence if possible
What to test when neuropathic bladder is being assessed?
Underlying cause including completeness of injury, bladder sensation, presence of urgency, TI what they want to do after, bowel function, sexual function, haematuria, urinalysis, US renal tracts with post-void measurement, flexible cystoscopy video urodynamics
What is hydro nephrosis?
Urine filling
What is gold standard of urine analysis?
Video urodynamics
What is video urodynamics?
pressure transducer in rectum, dual lumen pressure and filling line in bladder, intravesicular and intra abdominal pressure subtracted to calculate detrusor pressure and bladder filled with contrast and fluoroscopy screening
What is bladder compliance?
The ability of the bladder to change in volume without alteration in detrusor pressure.
What is a reflex bladder?
The reflex cycle is intact, so the detrusor doesn’t contract until required
What is an areflexive bladder?
the detrusor doesn’t contract or respond to the body’s signals
What can you deduce from a suprapontine dysfunction for bladder?
In the brain, Loss in ability to inhibit micturition. storage symptmes
What can you deduce form a spinal cord injury to bladder function?
Preserved micturition reflex as lower spine is intact but the coordination and inhibition of the reflex is disrupted so can have poor compliance
What can you deduce form a spinal cord injury to the sacral or infrasacra lesions to bladder function?
Have voiding dysfunction and wide range of dysfunction with the same injury
What are the managements for reflex bladder?
Anticholinergic drugs, intravesical Botox, agumentation cystoplasty or an Ileal conduit. Detrusor sphincter dyssynergia can have self catherterising, supra-ubic catheter, shincerotomy, agumention cystoplasty, ideal conduit
How can you treat an Areflexic bladder?
Clean intermitted self-catheter, suprapubic cathether, sphincterotomy, ileal conduit autologous fascial sling
What is automimic dysreflexia?
When have a spinal cord injury T6 or above that have a response to noxious stimulus tight clothing, Full bladder, fecal impaction pressure area and get sympathetic response, Tachycardia, High BP, body compensates above the injury but not below so below you get vasoconstriction cool and no sweating get headache
How to treat autoionic dysreflexia?
Sit patient up, 2 sprays of sublingual GTN, remove any tight clothing identify and treat noxious stimuli administer nifedipine 5-10mg contact anaesthetist ma requrie spinal anasesthetics while ongoing assessment
What is urinary incontinence?
Defined as the involuntary loss of urine mainly affects women
What are some common types of incontinenceclassification?
Transient delirium infection atrophic vaginitis pharmaceuticals psychiatrics causes endocrine causes restricted mobility stool impaction, Urgency, stress mixed, overflow, continuous
How to assess stress urgency incontinence?
When does it happen, haematurea are they pregnant, red flags for bladder cancer, PMH, Bowel and sexual function, abdominal and pelvic examination, cough test, DRE consider lower limb neurology Urinalysis
What is an ICIQ-SF form?
Validated form, for symptoms
What is the importance of a bladder diary?
The bladder funciton and incompetance levels
What is urge urinary incontinence?
Involuntary loss of urine preceded by sudden urgency
What is involved in pharmacology of urinary incontinence?
Anticholinergic, B3 agonists anticholinergics be carefe of acute angle glaucoma and myesthenia gravis
What is Itravesical botulinum toxin?
blocks ACh in junction to stop bladder contractin
What is sacral neuromodulation?
Releases signals in S3 to stop it from detrusor contracting
What is stress incontinence?
When intraabdominal pressure is increased, eg laughing coughing and sneezing usually due to hypermobile urethra or sphincter deficiency
What is conservative management of stress incontinence?
Lifestyle Pelvic floor muscle therapy, containment, duloxetine SNRI relaxes bladder and increases spincter resistance but lots of side effects
What is urethral bulking?
Submucosal injection of substance to increase urethral coaptation and outflow resistance for females only
What is burch colposuspension?
Surgery to support bladder neck used to be gold standard very good outcomes
What is an autologous fascial sling?
take some fascia, and make a sling to pass to anterior abdominal wall and support the urethra
What are synthetic tapes, nesh scandle?
Like autologous sling but synthetic and often caused chronic pain
What is management of stress urinary incontinency?
Muscle training then use insertion of urinary sphincter that’s artificial risk of erosion
What history is really important for bladder/ renal cancers?
Smoking, associated symptoms, UTI, catheters, Travel (parasites) exposure to carcinogens chemotherapy
What is a surgical sieve?
VITAMINDIC Vascular Inflammatory Traumatic Metabolic Infection Neoplastic Degenerative Idiopathic Congenital
What are the malignancies of the kidney?
Transitional cell carcinoma, adenocarcinoma, Squamous cell carcinoma which is rare usually due to stone injury or other
What is a paediatric problem with the kidney?
Wilm’s tumour nephroblastoma
What is an uncontrasted CT good for in renal cancer?
looking for kidney stones as they show up white
What is a contrast useful?
Gives detail of kidney tumour
What are oncocytoma and angiomyolipomas?
They are benign renal masses, oncocytoma thorught ot be from intercalated cells of collecting ducts other meenchymal full of blood vessels often watch and wait and remove all or part of kidney to treat
What can happen in advanced stages of renal cell carcinoma?
Local invasion and then into renal vein into righ atrium then bone brain or lung metasticies
What are the risk factors for renal cell carcinoma?
Smoking obesity renal failure, or VHL syndrome AD inheritance
What is the presentation of renal cell carcinoma?
Usually incidental others are or haematuria loin pain or masses also symptoms of metastatic disease, sometimes anaemia poycythaemia (EPO related), electrolyte imbalances Stauffer’s syndrome
What is stauffer’s syndrome?
Necrosis in liver causing dysfunction
What is infestigation for Renal cell carcinoma?
FBC LFT U&E Coag CT gold standard neede biopsy if needed
What are the managemetn of kidney cancer?
Partial nephrectomy open and mainly robotic surgery, radical nephrectomy laparoscopic or palliative for advanced disease, monitor or renal artery embolisation,
What treatment is not an option for Renal cell carcinoma?
Radiotherapy as it is not sensitive but chemo might not have much
What is Upper tract transitional cell carcinoma?
cancer of urothelium similar factors for bladder cancer, smoking and chemical exposure thre is chinese herb Aristolochia that causes it
What is presentation of Upper tract transitional cell carcinoma?
Haematurea and loin pain and often collic
How to treat UTTC?
Nephroureterectomy and can be respond to radiotherapy
What are the types of bladder cancer?
Transitional cell carcinoma, 90% squamous cell carcinoma metaplasia to dysplasia 5% uk but 75% eygypt shistosomaiasis, adenocarcinoma some very rare ones spindle cellcarcinoma melanoma lymphoma sarcoma
What is the epidemiology of TCC?
More common in men 2.5x and rare below 50 chemical carcinoges tobacco smike aromatic hydrocarbons dyes rubber diesel exhaust, industrial exposure hairdressers leatherworkers drivers and chemical workers soem drugs cause it Phenacetin, Cyclophosphamide and Pioflitazone
What is grading vs staging?
Dradig is how bad the tumour is under the microscope low or high whetehr it looks like orignal tisue stages is about how far it has spread
How are bladder cancers staged?
Tis in situ superficial but dangerous Ta T1 papillary low risk T2 muscle invasive T3a through muscle and T3b in fat around bladder T4a/b into surrounding organs
How do TCC spread?
Along inscisions or tracts. Suprapubic cathater don’t put it in if have cancer
Where does TCC metasticies?
Liver lung bone adrenal
When is blood in urine a problem?
painless visible blood is a problem. If non-visible is only a problem if persistant unexplained or dysuria or raised white cell count
What lower urinary tract symptoms are there for bladder cancer?
frequency urgency or nycturia
How to investigate Haemiaturia?
Flexible cystoscopy is gold standards, doesn’t take long Imaging US or CT,
What is CT urogram?
2 or so scans then one in the kidney then after
What is urine cytology?
centrifuge urine to look for CIS but not often done
What are the causes of persistant non visible haematurea?
commonly Benign prostatic hyertrophy, cancer of bladder kidney or prostate, stone disease or infection less common is radiation cystits urethreal stricture, TB medullart sponge kindey or Cyclophasphamaide systited or Kdne dieases rarely PKD renal paillar necrosis AV malformation divided into urological and nephrological
What is a transurethral resection?
It is treatment for bladder tumour, diagnostic and therapeutic often treats it by removing and can control haematurea,
What are the risks of Transurethral resection of Bladder tumour?
Risks, pain infection bladder perforation, might need 3 way catheter to wash out blood
What are intravesicle therapies?
Put into the bladder its chemotherapy that can reduce recurrance, Mitomicin C and BCG can be uses as immunotherapy to stop progression and stopping
What is treatment for Muscle invasive bladder cancer?
Radical cystoprstatectomy, as its very invasive and bad and lymphadonectomy, Diversion usually with an ilea conduit, chemotherapy and
What is neoadjuvant chemotherapy?
Before operation
What is prognosis of testicular cancer?
Most curable cancer very sensitive to chemotherapy, white mles highest risk, most common solid cancer men 20-45, Cancer 12x increasd cryptorchidism 6x increased risk HIV increases seminoma
What are the types of testicular cancers?
90% are germ cell tumours: 48% seminoma spermatocytic clasical and anapastic non seminoma42% teratoma yolk ac tumour or choriocarcinoma aosmtiems mixed leydic.sertoli other tumours are lymhomas carcinoid adenocarcinoma epidermoid cyst metastasis
How do testicular cancer diagnosis.
usually painless but can be hard mass arising from testis, check lymph nodes abdomen and lungs
What are investigations of testicular cancer?
USS to be done that day, tumour marcours X-ray for staging
What is LDH?
Tumour marker formass necrosis
What is testicular cancer treatment?
Radical inguinal orchidectomy curative in 75% then chemo for metastatic and high risk,
What is the function of the kidney?
Acid base balance, OPlasma calcium RBC EPO renin ECF volume electrolyte balance and excretion of soluble toxins
What influences GFR?
Hydrostatic pressure and colloid osmotic pressures, renal blood flow filtration coefficient affected by membranes
What is the purpose of renal auto-regulation?
Intrinsic feedback mechanism to minimise the impact of systemic arterial pressure variations to allow the filtration to remain relatively constant
What governs the afferent arteriole regulation?
the cells of the macula densa
How can NSAIDs cause direct kidney injury?
The affterent arteriol responds to prostaglandins from the macula densa but with NSAIDs this reflex is lost so can end up with Kidney damage from excess pressure
What is the tubuloglomerular feedback?
Renin-angiotesin system, Affterent and efferent are in contact with DCT throug macula densa low arterial pressure is low GFR and causes too much salt reabsorpton and this is sensed by macula densa then releases reneing and other effects
Where does angiotensin 2 act in the kidney?
Contracting the efferent arteriole
What is drawback of GFR as calculation fromcreatinine?
there is some tubular secretion of it that means an overestimation
What decreases GFR?
Filtration fraction decrease from renal disease DM hypertension, Increased Bowman capsule pressure rom UT obstriction, Increae in oncotic pressure from increased plasma proteins and reduced renal blood flow, decreased gomerular hydrostatic pressure
What ist the improtatnce of late distal tubule?
Responsive to ADH hey role in potassium secreetion sensitive to aldosterone and impermeable to water
What influence Extracellular fluid/
Insulin aldosterone beta 2 agonistas and alkalosis can reduce it . incresed by aldosterne deficiencey insulin dieficiency cell lysis exercise acidosis beta 2 antagonists
What happens i Conns syndrome?
Too much aldosterone gives increased K excretion increase cellular K uptakes reduced K in blood
What happens with too little aldosterone?
Increased loss of NaCl, reduces ECF sodium reduced plasma volume low BP circulatory reduced renal potassium excretion
What regulates BP in long term?
The kidney with JGA and macula densa
What happens in kidney failure?
GFR falls, Hypertension, Anaemia, Acidosis, CKD-Metabolic bone disorder, Abuminurea, Uraemia hyperkalaemia, Drug toxiciy and fluid overload
How do kidneys change pH of blood?
Regulation of Bicarbonate and H+ ions
How do kidneys change pH of blood?
Regulation of Bicarbonate and H+ ions
What are very late kidney failure sumptoms?
Hyperkalaemia, Uraemia
What is CKD metabolic bone disorder?
When get osteoporosis from too much bone resorption due to reduction of Vitamin D activation and reduction of absorption of Calcium which is why the bone is broken down
What is definition of CKD/
abnormality of kidney structrue or function present for >3months with implications for health
How is CKD staged?
based on G and A stage, G for GFR and A for albuminurea.
How to diagnose CKD?
eDFG<60ml/min and or urine ACR of >3mg/mmol
How do patients usually present with CKD?
Not usually it is caught by screening patients with comorbitites and those on drugs that can affect the kidney
What can cause CKD?
Diabetes mellitus, HTN atherosclerotic renovascular, Glomerulonephritis, Unknown infective or obstructive, Cystic or congenital miscellaneous MEDs Light chain disease
What risk factors affect progression of KD?
Race and underlying cause that can’t be modified, BP, level of proteinuria, exposure to nephrotoxic, underlying disease activity, further renal insults, Dyslipidaemia, increased phosphate, acidosis anaemia smoking glycaemic control
How to treat CKD?
Stop smoking, Dyslipidaemia control, control BP, reduce proteinuria using ACE inhibitor, controle diabetes well, phosphate binding drugs sodium bicarbonate for acidosis and replace iron and
How is treatment of advanced CKD?
Treat salt and water retetion using diet and later fluid restrictions and diuretics, hyperkalaemia diet and diruetics and potassium binders and treat metabolic bone disorder with screen for it and suppliment with calcium and vit D also plan and educate about kidney replacement therapy eg transplant or dialysis
What are the function of kidney replacement therapies?
removes waste products regulates electrolytes, removes salt excess water and acid but not Vit D EPO or fully correct levels
What are the three forms of Kidney replacement therapy?
Haemodyalysis, peritoneal dialysis, Transplant
What can glomerulonephritis cause?
Leaky glomeruli leading to haemoaturea and proteinurea and high blood pressure and deteriorating kidney funciton
Why is Glomerulonephritis important?
Becuase it causes 35% of end stage kidney failure
What is the cause of glomerulonephritis?
Immunologically mediated from immunoglobulin deposits and inflammatory cells and response to immunosupressive therapy
How can glomerulonerphitis present?
Acute nephritic syndrome, nephrotics sydreom, asymtomatic abnormalities of urine and CKD
What is nephritic syndrome?
Acute kidney injury, rapide deterioration in kidney function ans active dipstick with haematurea and proteinuria oligouria, hypertension and fluid overload
What can cause acute nephritic syndrome?
Goodpastures disease for anti basement membranes, ANCA asscociatd vasculitis, SLE systemic sclerosis post stre infection and IgA nephropathy
What are red cell casts?
RBC in fibrotic tissue seen on microscopy
How to tell someone has fluid overload?
Raised JVP and lung crepidations
Why are biological drugs only used for bringing disease under control not for maintenance?
They have side effects that are really bad
What is IgA nephropathy?
IgA glycosylation to deposition in mesangium
What are the clinical features of IgA nephropathy?
20-30s, episotic macroscopic haematuria, asymptomatic often, AKI at presentation or can have Cresentic GN only by
How to diagnose IgA nephropathy/
IgA in the mesangium form biopsy and cresents
How is IgA nephropathy treated?
Steroids, if severe or control BP ACE i or ARB to control proteinuria
Where is SLE nephritis more commone and iin who?
15-45yrs old more women than men and in non-white populations
What is Goodpastures syndrome?
Antiglomerular basement membrane Collagne 4, can get problems in lungs as well
What is nephrotic syndrome?
3 of the following:
Heavy proteinuria, Hypoalbuminaemia, Oedema hypercholesterolaemia, Haematuria usually absent or mild
How can protein excretion be measured?
albumin protein ratio to correct for conc of urine
What are causes of nephrotic syndrome?
Minimal change disease children adults, membranous nephropathey focal segmental glomerulosclerosis
Secondary, diabetes amyloid SLE infections Drugs malignancy
How is nephrotic syndrome usually treted?
Estabilsh cause
supportive diuretics ACEi/ARB spironolactone, Statins, Anticoagulate pts(clotting inhibitors are lost) prevent infections in children
What investigations for glomerulonephritis
Serum albumin, creatinine lipids glucose urinalysis, urine protein creatinine ratio, serum urineelectrophoresis, ANA antibodies etc
What causes erection of the penis?
Arterial dilatation and smooth muscle relaxation, activation of the corporeal veno occlusive mechanism
What makes up the corpus cavernosa?
The right and left crus
What makes up the corpus spongiosum?
Urethra, glans penis, bulb of penis
Which compartment of the penis hods the urethra?
The spongiosum
WHat suplies the penis with blood?
The internal iliac, internal pudendal artery leading to the dorsal penile artery, and cavernosal artery and bulbar artery
What is the action of blood vessels in penile tisue?
contraction of the helicine arteries and relaxation of veins opposte happens in erection
What is the nervous supply to the penis?
Parasympathetic erectile S2-4 and sympathetic T11-L2 passes posteriorly to prostate risk of damage in prostatectomy
What is the physiology of the erect state?
Parasympathetic stimulation of arteriolar dilatation and trabecular smooth muscle relaxation
What stimulates erections?
Higher stimuli, hypothalamus Oxytocin pro erectile pathways and spinal reflexes
What is a hormonal problem with erections?
Lack of testosterone from either primary pituitary or hypothalamus or secondart injury to testicles or congenital syndromes like kelinfelters and Noonans
What are the 3 main causes of erectile dysfunction?
Neurogenic failure to initiate, arteriogenic failure to fill and venogenic, failure to store
What can cause erectile dysfunctioon?
Age, Diabetes, Coronary artery disease, Dislipidaemia, trauma, hypogonadism, Drugs, psychosomatic
How do you assess erectile dysfunction?
how was onset, life stressors, early morning erections, is it situational, severity, any previous treatment, what are their expectations of functions
What to examine for erectile function?
Horome levels ECG, height weight BMI, check abnormalites, size of testicles, Rectal exams in LUTS, peno-scrotal exam
What tests for Erectile dysfunction?
Urinalysis, fasting blood glucose prolactine levels Ultrasound of vessels, Rigiscan for pressure
What are first line therapy of erectile dysfunction?
NO usually relaxes muscle so a PDE-5 inhibitor, to stop breaksdown of vasodilators
What is intraurethral suppository?
Prondglandins in urethra causes cAMP to get an erection
What is intracavrnosal injections?
Inject into the penis cavernosa to cause erection
What is the penis implant?
Pump in scrotum reservoir in abdomen
Why is prostate cancer important?
Most commonly diagnosed cancer in men
What is prostate cancer?
adenocarcinoma of the prostate usualyl in peripheral zone and most are multifocal, spreads locally through prostate capsule, metastasisesto lymph nodes and bone occassionally to lung liver and brain
What are prostate biomarkers?
Tissue serum Prostate-sepecific antigen or prostate-specific membrane antigen uine PCA3 and gene fusion products
What is PSA?
Serine protease responsible for liquefaction of semen small amount of retrograde leakage which is enough to be detected in small quantities in the blood
What is problem with PSA?
70% of men with elevated PSA will not have cancer and 6% without do have cancer
How is prostate cancer diagnosed?
Lover urinary tract symproms, prostate specific antigen, Transrectal ultrasound scan, prostate biopsy, prostate cancer grading
What grading system is used in prostate cancer?
Gleason grading 2 most common scores can be grouped into grade group
What is the treat ment for localised prostate cancer?
Curative surgery radical prostatectomy radiotherapy with hormones or watch and wait
What are the treatments for prostate cancer that is locally advanced?
surgery or radiotherapy with neoadjuvant hormone therapy
How can cancer be staged?
TNM T1 no palpable tumour, T2 plapable tumour confind to prostate T3 palpable tumour extending beyond prostate T4 is into muscle Nlymphnodes and M for metastasies
What is androgen sensitivity in prostate cancer?
Androgens stimulate gene translation of oncogenes
Why should we screen for prostate cancer?
It is very common, responsible for many deaths, 3% of men will die of it
Why might we not screen for prostate cancer?
Uncertain natural history and could overtreat and create out own morbidity
What is brachytherapy?
localised seeds of radioactive material
What are pros and cons of radical treatment for localised prostate cancer?
Curative, high mortality in prostate cancer, reduced anxiety, longditudinal studies showing benefit of surgery but its disease of elderly, competing causese of death, 30%
What is used to stratify risk of prostate cancer?
PSA level Gleason grade volume of tumour on biopsy and MRI appearance
What is a UTI?
Urinary tract infection caused by he presence and multiplication of microorganisms in the urinary tract, combination of clinical features and bacteria in the urine
What are the diseases that can be classed as a UTI?
Cystitis, Prostatitis, Epididymitis/orchiditis, urethritis and Upper tract pyelonephritis
How can a UTI be classified?
Asymptomatic bacteriuria, uncomplicated and complicated
What is Pyuria?
Presence of leucocyted in the urine associated with infection but can get steril pyuria
How common is asymptomatic bacteruria?
Quite common especially in females more than males and in older people rather than younger people
What classes as complicated vs uncomplicated UTI?
Uncomplcated is non pregnant woman, everything else is complicated pregnant, men catheterised children recurrant or persistant immunocompromised nosocomial infection structureal abnormality urosepsi
Which bacteria usually cause UTIs?
E.coli Proteus, Klebsiella, enterococci staph. srophyticus S aureus and Pseudomonas aruginosa
What is the usual pathogenisis of a UTI?
Clolonic flora, colonisation of vagina, colonisation of urethral meatus, ascent of bacteria, UTI
What factors can make UTI more likely?
Kidney stones, stasis in the ureters, reflux in ureters, Short urethra in women, catheterisation can introduce bacteria, obstruction of the bladder or a tumour or stone can cause this
What is the effect of oestrogen on UTI?
Normal vagina colonised with lactobacilli maintain low pH from lactate producion post menopause pH rises and allows olonic flora to colonise and reduced vaginal mucus secretion making it more likely to get infection
What are the symptoms of a UTI?
Pain or burning when weeing(Dysuria), needing to wee during the night, cloudy urine, needing to go suddenly more frequen, blood in urine lower tummy pain or bac pain high temperature and feeling hot and shivery
Children can have high temperature and can be irritable wet the bed or be sick
How is UTI diagnosed?
Urine dipstick or urine culture
How can a UTI be investigated?
Bloods, Glucose, Protein, pH, Glucose, leucocytes, nitrates, Ketones pH, in urine
What signifies renal involvement in urine?
Casts
When should Asymptomatic bacteriuraemia be treated?
Only in younger patients
When should a Urine culture be done?
when it is uncomplicated or in children
When should a urine culture not be done?
Not in uncomplicated just treat empirically, my need to adjust antibiotics, also void pre and post intercourse increase fluid intake and better hygiene 3 day
What are the types of urne sample?
Mid stream urine, Catheter urine sample, Bag urine, early morning urine, Clean catch urine, Suprapubic aspirate,
What to look at microscopy of ?
WBC RBC casts bacteria epithelial cells
What can cause sterile pyuria?
Antibiotic taking or other causes like intracellular organisms schistosomiasis
How long does complicated UTI take?
7 days
What is first lie antibiotics?
Nitrofurantoin, as don’t want to use broad spectrum antibiotics
What is important with cathater?
Dipstick for infection and culture is not great as always colonised
What is a biofilm?
a layer on a device that allows bacteria to protect themselves
How to prevent catheter infections?
prompt removal of catheter, termproary if possible and only treat if symptomatic
What is problem for UTI in pregnancy?
increases with age parity sexual activity diabetes
What to do in pregnant women?
Treat asymptomatic so send culture,
What is pyelonephritis?
infection of kidneys and ureters
What are symptoms of pyselonephritis?
pain pyruria and fever
What can casue pyelonephritis?
Ascending from lower UTI haematogenous and lymphatic
What to investigate pyleonephritis?
tender loin renal angle tenderness
What is treatment of pyelonephritis?
Fluid replacement IV antibiotics drain obstructed kidney catheter analgesia and long term antibiotics
What are the complication of pyelonephritis?
Renal abscess and can have Emphysematous pyelonephritis
What should be investigated in cases of recurrent complicated UTI?
urine sample, examination DRE PV, Post void bladder scan, USS renal tract pelvis maybe Xray for stoens or flexible cystoscopy
When treating UTI in a patient with a catheter what should be done?
change or remove the catheter when starting treatment
What is most common infection in short term catheter?
monomicrobial infections
What are the complications of long term catheters?
Chronic inflammation obstructions stones UTI/Pyelonephritis
What is a risk if UTI not treated in pregnancy?
Pyelonephritis even if asymptomatic it is 20-40% risk
What is prostatitis?
Inflammation /swelling of the prostate gland, affects 35-50% OF MEN
Who gets kidney stones?
More males than females, 30-50 high recurrence
Where can you get stones?
Anywhere form collecting duct to distal urethra
Where are stones usually formed?
In the kidneys, and bladder
What puts you at risk of stones?
congenital kidney structure issues or aquired anatomical factors like bladders, also urinary factors like metastable (too much salt) urine promotors or inhibitors calcium oxalate urate and cystine levels and dehydration infections
What are mechanisms that usually prevent formation of stones?
Good hydration, low salt diet, normal dairy intake, moderate protein intake reduce BMI (medabolic syndrome), active lifestyle
What are most stones made of?
Calcium oxaloate, (most of them)phosphate, uric acid 5-10 struvite or cystine
What is a rare reason for kidney stones?
Hypercalcaemia from PTH
Hoe can interventions reduce risk of stones?
Alkalinate urine through bicarbonate
What are presntation of kidney stones?
Asymptomatic caught on other scans, renal collic loin pain UTI symptoms Blood in urine (non-visible usually)
What is classic pain for stones?
Unilateral loin pain. rapid onset, sharp searing burning, unable to get comfortable, radiates to froin ipsilateral testis labia, associated with nausea and vomiting, spasmodic colicky worse with fluid loading classically severe
What to assess in renal collic?
ABC give analgesia, Non contrast CT vers sensitive for stones99 and specific 90,
What is differential diagnosis in renal collic?
AAA, Bowel pathology divertoculitis appendicitis gynae ectopic pregnacy ovarian cyst testicular torsion MSK
How to interpret kidney ct?
Count kidneys look at size and thickness, area around them
How are ultrasound used in stone disease?
Good for fluid in kidney poor visualisation of stines in ureter
What are IVU?
Contrast to look at the flow through kidney not used much
What is management of Ureteric?
NSAID suppository for pain, paracetamol IV or opioids anti emetics, might need admitting i pain not settling or AKI watch out for sepsis
Why is sepsis a problem with kidneys?
can infect the kidney, IV antibiotics drain the kidney and treat sepsis. can loose kidney fuction in 24hours
How are renal stones treated conservatively?
Just manage prevent getting worse, small peripheral
What affects treatments
Size location of stone and patient factors and complications/risks
Are stones dangerous?
Small can migrate to ureter, large can obstruct calyces can cause renal collic, can cause renal damage and small stones doent cause problems in 75%
What is lithotripsy?
Shockwaves to break stones up from surface
What is PCNL?
keyhole removal of stone from kidney
How are ureteric stones treated?
always removed unless very small, bigger stones do Lithotripsy or ureteroscopy any stone laser basket extraction lithoclast drainage if sepsis nephrostomy or insert a stent
How are bladder stones treated?
Some are conservative, endoscopic can be accompanied by treatment of BOO BPH related, Open laproscopiic surgery ideal for larger stoens
What is ESWL?
shockwaves use Xray guidance
What is done in flexible cystoscopy?
They send up use drill or laser to break up stones and basket to remove it
What is nerphritic syndrome?
AKI with inflammation Blood and protein in urine fluid overload
What are complications of acute nephritic syndrome?
Retinal bleeding, fair leeding and hypertension
What is nephrotic syndrome?
Heavy proteinrea, Hypoalbuminaemia, oedema, hypercholesterolaemia, haematuria usually absent or mild 3 of those
What can cause primary nephrotic syndrome?
minimal changechildren and adults, membranous or focal segmental glomerulosclerosis. Black adults
What characterises minimal change?
Podocyte falling off
What can cause secondary nephrotic syndrome?
Diabetes Amyloid, infections SLE Drugs malignancy
