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Clinical Pathology > Theme 4 Lecture 1&2: Pathology of the urogenital tract > Flashcards

Theme 4 Lecture 1&2: Pathology of the urogenital tract Flashcards

1
Q

What connects the kidney to the bladder?

A

ureter

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2
Q

What is renal cell carcinoma?

A
  • cancer of the kidney that arises from the renal tubular epithelium
  • cancer of the renal collecting ducts
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3
Q

What are the two most common types of renal cell carcinoma?

A
  1. clear cell (75%)

2. papillary (10%)

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4
Q

Who is at increased risk of renal cell carcinoma?

A
  • 60+ yo
  • M > F
  • PMH of: obesity, smoking, NSAID use, ESRF and on dialysis
  • family history (especially Von Hippel-Lindau)
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5
Q

What is von hippel lindau?

A
  • inherited gene mutation in VHL
  • pre disposes to renal cell carcinoma
  • formation of tumours and cysts on organs
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6
Q

What are the local effects of the primary tumour in renal cell carcinoma?

A
  • haematuria

- abdominal pain

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7
Q

Can renal cell carcinomas metastasise? if so where?

A
  • lung mets causing SOB

- bone mets causing bone pain etc

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8
Q

What is a paraneoplastic syndrome?

A

signs and symptoms NOT related to the local effects of the primary or metastatic tumours

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9
Q

What are the paraneoplastic syndromes in renal cell carcinoma?

A
  • weight loss / “cancer cachexia”
  • hypertension
  • polycythaemia (high conc of RBCs in blood)
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10
Q

Why would renal cell carcinoma cause hypertension?

A

because one of the jobs of the kidney is to produce renin, which regulates blood pressure
so if we are producing excess renin, the system will become inbalanced

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11
Q

Why do paraneoplastic syndromes develop?

A

As a result of either:

  • proteins/hormones secreted by tumour cells
  • immune cross reactivity between tumour cells and normal tissues
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12
Q

Why would patients with renal cell carcinoma develop polycythaemia?

A

tumour produces erythropoietin (hormone involved in stimulating production of RBCs)

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13
Q

What is a Wilm’s tumour?

A
  • a.k.a nephroblastoma

- cancer of the kidney that arises from nephroblasts

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14
Q

What are nephroblasts

A

cells that develop into the kidney in embryological development?

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15
Q

Who is at increased risk of developing a Wilm’s tumour?

A
  • children under 5 (‘blastoma’)
  • 5/10% associated with genetic syndromes including:
  • Beckwith-weidemann syndrome (overgrowth syndrome)
  • WAGR syndrome
  • Denys-drash syndrome
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16
Q

A mutation in which gene is responsible for beckwith-wiedemann syndrome?

A

WT1

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17
Q

What are the local effects of the primary tumour in Will’s tumours?

A
  • extensive abdominal distension (especially if bilateral which 10% are)
  • haematuria
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18
Q

What are the effects of distant mets and paraneoplastic syndromes in Wilm’s tumour?

A

Mets and PNS are rare

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19
Q

What are urolithiasis?

A
  • urinary tract calculi/stones e.g kidney stones

- stones forming in the lumen of the urinary tract, anywhere from the renal calyx –> bladder

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20
Q

What are the 4 types of calculi?

A
  1. calcium stones (70%)
  2. urate stones (5%)
  3. cystine stones (1%)
  4. Struvite stones (15%) (magnesium ammonium phosphate)
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21
Q

What causes a calculi? (calcium, urate and cystine stones only)

A
  1. too high a concentration of soluble material
  2. urine becomes saturated
  3. soluble material precipitates out
  4. stones form
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22
Q

What causes calcium stones?

A

hypercalcemia

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23
Q

What causes urate stones?

A

gout, malignancy (high cell turnover)

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24
Q

What causes cystine stones?

A

congenital cystinuria - kidneys unable to reabsorb amino acids

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25
Q

What causes struvite stones?

A

urinary tract infection

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26
Q

What is the pathogenesis behind the formation of struvite stones?

A
  1. you need a UTI with a bacteria that produces urease e.g proteus
  2. urease converts urea to ammonia
  3. ammonia causes pH rise
  4. precipitation of magnesium ammonium phosphate salts
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27
Q

WHat are the clinical features of calculi?

A
  • pain
  • if stone is in ureter: pain is “loin to groin” - pain that shoots from back to bladder
  • bladder: lower abdominal pain
  • urethra: dysuria (stinging when urinating)
  • haematuria
  • +/- symptoms of complications
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28
Q

How can we tell a calculi is made of calcium from an X-ray?

A

calcium is radio-opaque so it comes up as white on the X-ray - we can see a white stone where the ureter would be

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29
Q

What are the possible complications of urolithiasis?

A
  1. obstruction = hydronephrosis +/- hydroureter = excess water puts pressure on kidney causing renal impairment
  2. urinary stasis = increased risk of infection
  3. local trauma = squamous metaplasia - squamous cell carcinoma risk
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30
Q

What is vesicoureteral reflux?

A

when the urine flows backwards from the bladder to the ureter, rather than from the bladder to the urethra

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31
Q

Who is at risk of developing vesicoureteral reflux?

A
  • affects 10% of population
  • young people, especially < 2 YO
  • more common in those with family history of VUR
32
Q

what causes vesicoureteral reflux?

A

congenital abnormality of vesicoureteric junction (at the site where the ureter and the bladder meet)

33
Q

What is the pathogenesis that causes vesicoureteral reflux?

A
  1. ureter enters bladder at abnormal angle –> shorter intramural ureter
  2. when voiding, muscle in bladder wall contracts but there is not enough muscle in contact with ureter to compress it –> ureter remains patent –> urine flows the wrong way
34
Q

What are the clinical features of VUR?

A
  • usually asymptomatic
  • most children “grow out of it”
  • only symptoms of complications
35
Q

What are the complications of VUR?

A
  • stasis = UTI (any stasis of urine in the urinary tract becomes a breeding ground for bacteria so increases likelihood of UTI)
  • back pressure and ascending infection = renal damage
  • hydroureter followed by hydronephrosis
  • in hydronephrosis, as the urine puts more pressure on the renal tissue, the renal tissue gets thinner and there is a reduced renal function
36
Q

What are the 3 conditions affecting the ureter?

A
  1. urolithoasis
  2. VUR
  3. urothelial carcinoma
37
Q

What is urothelial carcinoma

A
  • a.k.a transitional cell carcinoma
  • cancer arising from urothelium
  • big giant cells on the top are the cells that are able to stretch when the bladder fills with urine
38
Q

Who is at increased risk of urothelial carcinoma?

A
  • age > 60
  • M > F
  • smokers
  • exposed to certain industrial chemicals - as these chemicals eventually end up in urine and sit in the bladder before going to the toilet
  • family history
  • treatment for other cancers e.g pelvic radiotherapy, cyclophosphamide
39
Q

What causes urothelial carcinoma?

A

strong association with environmetnal factors such as arylamines (dyes, rubbers, pesticides) and smoking

40
Q

What are the effects of the primary tumour in urothelial carcinoma?

A
  • haematuria
  • frequency, urgency, dysuria
  • urinary obstruction
41
Q

Where can urothelial carcinomas metastasise to?

A
  • lung mets
  • bone mets
  • liver mets
42
Q

What is neurogenic bladder?

A

inability to properly empty the bladder due to neurological damage

43
Q

What are the two types of neurogenic bladder?

A
  1. spastic: if damage is to brain or spinal cord (upper motor neuron) - too much tone
  2. flaccid: if damage is to peripheral nerves (lower motor neuron) - too little tone
44
Q

What can cause the upper motor neuron damage leading to spastic neurogenic bladder?

A
  • stroke
  • MS
  • spinal injury
45
Q

What can cause the lower motor neuron damage leading to flaccid neurogenic bladder?

A
  • pregnancy (usually temporary)
  • diabetes - effects peripheral nerves
  • alcohol (B12 deficiency)
46
Q

Explain the mechanism causing neurogenic bladder?

A
  • as the bladder fills, stretch receptors in the bladder wall tell the reflex nerves in the spinal cord that the bladder is full
  • motor nerves stop the bladder from emptying until impulses in the brain override the motor nerves and allow the bladder to empty
47
Q

What are the clinical features of neurogenic bladder?

A

symptoms related to lack of control of bladder entry –> urinary retention +/- abdominal distension, incontinence, urge, frequency

48
Q

What are the complications of neurogenic bladder?

A
  • stasis –> urinary tract infection –> dysuria etc
  • stasis –> urinary stones –> haematuria
  • inability to empty bladder –> bladder distension –> hydroureter –> hydronephrosis –> renal function impairment –> oedema etc
49
Q

What is benign prostatic hyperplasia (BPH) ?

A
  • increased number of both stromal and glandular cells in the prostate
  • known by patients as an ‘enlarged prostate’
50
Q

Who is at increased risk of BPH?

A
  • old men
  • obesity
  • diabetes
  • FH
51
Q

What causes BPH?

A
  • cause is essentially unknown

- it is hypothesised that it is hormone mediated related to dihydrotestosterone (DHT)

52
Q

What is acute urinary retention?

A

patient suddenly can’t urinate and often has to be admitted to hospital to be catheterised

53
Q

Explain how BPH causes complications?

A

detrusor muscle hypertrophy - enlarged prostate blocks urether making it difficult to pass urine so the bladder works extra hard to force urine through urether

54
Q

What are the clinical features of BPH?

A

lower urinary tract symptoms (LUTS):

  • hesitancy or urgency
  • poor/intermittent stream
  • straining
  • prolonged micturition (urination)
  • incomplete bladder emptying
  • dribbling
  • frequency
  • incontinence
  • nocturia (waking up in the night needing to urinate)
55
Q

What is prostatic adenocarcinoma?

A

cancer of the glandular epithelium in the prostate

56
Q

Who is at increased risk of prostatic adenocarcinoma?

A
  • old men
  • black men
  • family history (inc. BRCA1/2)
  • pesticide exposure
  • obesity
  • as the main risk factor for BPH is also age, the two are often seen in the same patient, but BPH is not precursor to cancer
57
Q

What are the local effects of the primary tumour in prostatic adenocarcinoma

A

LUTS - hesitancy, dribbling etc

58
Q

Where can a prostatic adenocarcinoma metastasise to?

A

bone

59
Q

What is cryptorchidism?

A
  • undescended testis
  • testis is somewhere NOT in the scrotum
  • types based on sites of testis
60
Q

Where can testis sit in cryptorchidism?

A
  • abdomen (15%)
  • inguinal canal (25%)
  • high scrotal (60%)
61
Q

Who is at increased risk of cryptorchidism?

A

premature babies (but still present in 3% of those born full term

62
Q

What genetic conditions can cause cryptorchidism?

A
  • family history
  • downs syndrome
  • kleinfelter syndrome
63
Q

What environmental factors can lead to cryptorchidism?

A
  • low birth weight
  • maternal smoking
  • maternal alcohol
  • prematurity
64
Q

Explain the embryological process of the descent of testis into the scrotum?

A

7 weeks: tests begin to form (in abdomen)
10-15 weeks: transabdominal descent
25-35 weeks: inguinoscrotal descent

65
Q

What are the complications of cryptorchidism?

A
  • infertility
  • hernias
  • testicular cancer risk
  • testicular torsion - when the testis spins on axis and chops off its own blood supply
66
Q

What is a seminoma?

A
  • malignant neoplasm of the testis arising from germ cells in the seminiferous tubules
  • most common testicular cancer
67
Q

Who is at increased risk of seminoma?

A
  • young men (25-45 YO)
  • family history
  • cryptorchidism
68
Q

What are the clinical features of seminoma?

A
  • testicular lump
  • swelling
  • dull ache or pain
  • shrinking
  • increased firmness
  • swelling or enlargement
  • heavy feeling
  • hard lump
  • difference between testicles
  • fluid
69
Q

Where can a seminoma metastasise to?

A
  • lung mets –> SOB etc

- lymph nodes –> back pain

70
Q

Which paraneoplastic syndrome is associated to a seminoma?

A

gynecomastia (if hormone BHCG is produced)

this is enlargement of the breast tissue in males

71
Q

Which type of calculi have a distinguishable stag horn appearance on X-ray?

A

struvite stones

72
Q

What is phimosis?

A

a condition in which the foreskin can’t be retracted (pulled back) from around the tip of the penis

73
Q

Why do most types of obstructions occur in the ureter?

A

its a thin tube so easier to become blocked

74
Q

What are the symptoms of a complete obstruction of the urinary tract?

A
  • anuria (no urination at all)
  • pain
  • partial obstruction - often asymptomatic
75
Q

What are the complications of an obstruction of the urinary tract?

A
  • irreversible renal impairment
  • secondary VUR
  • infection (due to urinary stasis)
  • calculi formation

Clinical Pathology (57 decks)

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