Urinary 2 Flashcards
What are the indications for renal imaging?
Renal colic and renal stone disease >Diagnosis and follow up Haematuria Suspected renal mass UTIs Hypertension
What imaging is used for kidneys?
Plain X-ray
USS
CT
What are the clinical features of nephrourolithiasis?
Renal pain (fixed in loin) Ureteric colic (radiating to groin) Dysuria / haematuria / testicular or vulval pain Urinary infection Loin tenderness Pyrexia
How do you investigate kidney stones?
Bloods, Urine analysis
Parathyroid hormone
Radiology
What are the indications for surgery and renal stones?
Obstruction Recurrent gross haematuria Recurrent pain + infection Progressive loss of kidney function Patient occupation
What are the indications for PCNL?
Large stone burden (risk of Steinstrasse) Associated PUJ stenosis. Infundibular stricture. Calyceal diverticulum. Morbid obesity or skeletal deformity. ESWL resistant stones e.g. Cystine. Lack of availability of ESWL.
What are the complications of PCNL (surgery)?
Uncorrected coagulopathy.
Active Urinary Tract Infection.
Obesity or unusual body habitus unsuitable for X-ray tables.
Relative contraindications include small kidneys and severe perirenal fibrosis.
What is ESWL, when is it used?
Extracorporeal wave lithotripsy
Not used as first line with stones greater than 2cms
Not as effective after 2 treatments
What are the indications for ESWL?
Severe obstruction, uncontrollable pain, persistent haematuria, lack of progression, failed ESWL and patient occupation
What are the complications of uteroscopy?
Minor complications: 0-30%
>Haematuria, fever, small ureteric perforation, minor vesico-ureteric reflux.
Major complications:
>Major ureteric perforation, ureteric avulsion, ureteral necrosis and stricture formation.
What is the clinical presentation of bladder stones?
Suprapubic / groin / penile pain Dysuria, frequency, haematuria Urinary infection (persistent) Sudden interruption of urinary stream Usually secondary to outflow obstruction
How do you treat bladder stones?
Endoscopically
Large stones with open excision
What systemic diseaes affect the kidneys?
Diabetes mellitus Cardiovascular disease >Cardiac failure >Atheroembolism >Hypertension >Atheroscelrosis Infection Inflammation in blood vessels Myeloma Amyloidosis Drugs
What drugs affect the kidneys?
Aminoglycosides ACEI Penicillamine NSAIDs Radiocontrast
What are the types of vascalitis?
Aorta/large artery >Takayasu arteritis >Giant cell arteritis Medium artery >Polyarteritis nodosa >Kawasaki disease Small vessel >Wegener’s granulomatosis >Microscopic polyarteritis Churg-Strauss syndrome
What is wegners granulomatosis?
Granulomatous inflammation in respiratory tract
Focal necroitising glomerulonephritis with crescents
Affects all age groups
What is the clinical presentation of vasculitis?
Upper respiratory tract >Epistaxis, sinusitis >Cough, dyspnoea, haemoptysis >Pulmonary haemorrhage Kidney >- glomerulonephritis Joints > arthralgia, myalgia Eyes > scleritis Heart >pericarditis Systemic > fever, weight loss, vasculitic skin rash
How do you diagnose vasculitis?
Yrine blood/protein Raised urea Low albumin, Raised Alk P Anaemia Hyperglobulinaemia Positive ANCA
How do you diagnose multiple myeloma?
bone marrow aspirate
Serum para protein
urinnary Bence Jones protein
skeletal survey
What are the complications of multiple myeloma?
cast nephropathy light chain nephropathy amyloidosis hypercalcaemia hyperuricaemia
How do you diagnose multiple myeloma?
Urine protein, microscopic blood Elevated urea, creatinine + CRP Anaemia Raised alk P ANCA
What are the clinical features of multiple myeloma?
Hands >splinter haemorrhages, purpura face >scleritis, uveitis, nasal cartilage deformity, retinal vasculitis, hypertensive retinopathy Skin >Vasculitic rash, scleroderma CVS >Hypertension, murmur Chest >Crepitations, haemoptysis Locomotor >Joint swelling, tenderness CNS >Stroke, encephalopathy
What are the common sites of urinary tumours?
Epithelial lining
Bladder
What is the pathology of bladder cancer?
Most often transitional cell carcinoma
If schistomosomiasis is endemic, squamous cell carcinoma
What are the risk factors for transitional cell carcinoma?
smoking (accounts for 40% of cases)
aromatic amines
non-hereditary genetic abnormalities (e.g. TSG incl. p53 and Rb)
What are the risk factors for squamous cell carcinoma?
Schistosomiasis (S. haematobium only)
chronic cystitis
cyclophosphamide therapy
pelvic radiotherapy
What are the symptoms of bladder cancer?
Visible often painless haematuria
Occasionaly symptoms due to invasive or metastatic disease
Recurrent UTI
Storage bladder symptoms
How do you investigate haematuria?
Urine culture
Cystourethroscopy
Upper tract imaging
>Intravenous urogram/US
How do you diagnose urothelial tumours?
IVU will miss some renal cell tumours
USS alone will miss urothelial tumours of upper tracts
What are the different stages of bladder cancer?
G1 = Well diff. - commonly non-invasive
G2 = Mod. diff. - often non-invasive
G3 = Poorly diff. - often invasive
Carcinoma in situ (CIS) – non-muscle invasive but VERY aggressive (hence treated differently)
How do you treat low grade bladder cancer (no muscle involvement)?
endoscopic resection followed by single installation of intravesical chemotherapy (mitomycin C) within 24 hours
prolonged endoscopic follow up for moderate grade tumours
consider prolonged course of intravesical chemotherapy (6 weeks to 6 months) for repeated recurrences
How do you treat invasive bladder cancer?
Chemo + radio
Or chemo + surgery
What are the symptoms of upper tract urothelial cancer?
Frank haematuria
Unilateral ureteric obstruction
Flank or loin pain
Symptoms of nodal or metastatic disease
What is UTUC?
Renal pelvis or collecting system most commonly, sometimes ureter
High grade multifocal unilateral
Endoscopic treatment
What are the renal tumours?
Benign : oncocytoma, angiomyolipoma
Malignant : renal adenocarcinoma commonest adult renal malignancy
What are the histological subtypes of renal adenocarcinoma?
clear cell (85%)
papillary (10%)
chromophobe (4%)
Bellini type ductal carcinoma (1%)
What are the risk factors of renal adenocarcinoma?
Family history (autosomal dominant e.g. vHL, familial clear cell RCC, hereditary papillary RCC; can be bilateral and/or multifocal) Smoking Anti-hypertensive medication Obesity End-stage renal failure Acquired renal cystic disease
What is the presentation of renal adenocarcinoma?
Asymptomatic (i.e. incidentally noted on imaging for unrelated symptoms) : 50%
‘Classic triad’ of flank pain, mass and haematuria : 10%
Paraneoplastic syndrome : 30% anorexia, cachexia and pyrexia hypertension, hypercalcaemia and abnormal LFTs anaemia, polycythaemia and raised ESR Metastatic disease : 30% >bone, brain, lungs, liver
How do you investigate renal adenocarcinoma?
CT scan
Bloods
US, IVU, DMSA
How do you treat renal adenocarcinoma?
Surgical
Radio/chemoresistant (mets difficult to treat)
Immunotherapy
What are the predisposing factors to UTIs?
Immunosuppression Steroids Malnutrition Diabetes Female Sexual intercouse Congenital abnormalities Stasis of urine Foreign bodies (catheters, stones) Oestrogen deficiency Fistula between bladder and bowel
What organisms generally cause a UTI?
Generally bowel oganisms
E coli mos common
How do UTIs transfer into the urinary tract?
Transurethral route >Perurethral area contaminated >>Recurrent UTIs, diaphragms, ? bubble baths >Urethra to bladder >>Intercourse, catheterisation >Bladder (and up ureters) Bloodstream Lymphatics
What are the clinical features of UTIs in children?
Diarrhoea Excessive crying Fever Nausea and vomiting Not eating
What are the clinical features of UTIs in adults?
Flank pain Dysuria (“like passing broken glass”) Cloudy offensive urine Urgency Chills Strangury Confusion (very old people)
What are the clinical features of pyleonephritis?
Pyrexia Poor localisation Loin tenderness (renal angle) Signs of dehydration Turbid urine
How do you investigate a UTI?
MSSU (midstream sample of urine)
Urinalysis
Microbiology
> Identify organism so you can treat
How do you treat a UTI?
Fluids Antibiotics > Trimethoprim - first line >Amoxicillin (3-5 day course or 3g x 2), >cephalosporin Severe infections >Intravenous antibiotics
What is reflux?
Urine going back to kidneys
Often happens in children
How do you manage reflux?
Assess progression of reflux by USS
Surgery if needed
What are the potential complications pf pyleonephritis?
Radiological diagnosis Scarring & clubbing Hypertension / CRF Reflux 15% progress to renal failure
What are the risk factors of prostate cancer?
Age (old) Ethnicity Family history Food? Drugs
What is the presentation of prostate cancer
Mainly asymptomatic If not, then often LUTS diagnosed through PSA testing >then digital rectal examination >and prostate biopsies PSA prostate specific not cancer specific
What is PSA?
Prostate specific antigen A Serine protease - liquifies semen half of 2.2 days normal range of 0 to 4 µg/mL levels increase with age
What can cause elevation of PSA?
UTI chronic prostatitis physiological recent urological procedure, insurance prostate cancer BPH
How do you treat prostate cancer?
Immediate hormonal therapy is mainstay of treatment
Supportive treatment : e.g. palliative radiotherapy to bony metastases, colostomy, nephrostomy, zoledronic acid, palliative care support, etc.
Hormone refractory stage will be reached in 18-24 months of treatment
Oestrogen can be tried
Surgery possible
How does testicular cancer present?
Usually painless lump Sometimes: >Tender inflamed swelling >history of trauma >signs and symptoms for distant nodal metastases
What are the tumour markers for testicular cancer?
AFP (alpha-fetoprotein) (teratoma)
Beta-HCG (Human Chorionic Gonadotrophin) (seminoma)
LDH (Lactate dehydrogenase) (non-specific marker of tumour burden)
How do you diagnose testicular cancer?
ump in testes are testicular tumours until proven otherwise
look for tumour markers
perform testicular ultrasound and x-ray
What are the differentials for testicular cancer?
differentials
>infection
>epididymal cyst
>Missed testicular torsion
How do you treat testicular cancer?
orchidectomy further treatment dependent on type Low stage, negative markers >Surveillance; or >Adjuvant radiotherapy (SGCT only); or >Prophylactic chemotherapy Nodal disease, persistent tumour markers, or relapse on surveillance >Combination chemotherapy (BEP); or > Lymph node dissection (NSGCT only) Metastases >First-line chemotherapy >Second-line chemotherapy
What is the pathology of testicular cancer?
Germ cell tumour (95%)
>Seminomatous GCT (classical, spermatocytic, or anaplastic) 30-40yrs
>Non-seminomatous GCT (teratoma, yolk sac, choriocarcinoma, mixed GCT) 20-30yrs
Non-GCT (sex cord/stromal):
>Leydig
>Sertoli
>Lymphoma rare
