Urinary

Question 1

How would you manage a patient with hypokalaemia?

Answer 1

Oral K+ supplements and slow IV potassium.

Question 2

How would you manage a patient with hypomagnesaemia?

Answer 2

Oral magnesium salts.

IV magnesium sulfate.

Question 3

How would you manage a patient with hypocalcaemia?

Answer 3

Vitamin D and calcium supplementation.

Furosemide with IV fluids.

Question 4

How would you manage a patient with hypomagnesaemia and hypokalaemia/hypocalcaemia?

Answer 4

Magnesium supplementation, with potassium/calcium.

Question 5

How would you manage a patient with heart failure?

Answer 5

Symptoms - loop diuretics eg furosemide and bumetanide.
Long term - aldosterone antagonists (potassium sparing diuretic) eg spironolactone.
ACE inhibitors/ Ang II antagonists and beta-blockers.

Question 6

What diuretics are used to treat acute pulmonary oedema?

Answer 6

Loop diuretics eg furosemide and bumetanide.

Question 7

What diuretics are used to treat fluid retention and oedema in nephrotic syndrome, renal failure and cirrhosis of the liver?

Answer 7

Loop diuretics eg furosemide.

Spironolactone (aldosterone antagonist) preferred for cirrhosis of the liver, but loop diuretics added if needed.

Question 8

How would you manage a patient with hypertension?

Answer 8

Thiazides diuretics eg bendroflumethiazide.
Spironolactone (if primary hyperaldosteronism).
Loop diuretics (if renal failure).
ACE inhibitors/Ang II antagonists and beta-blockers.

Question 9

What diuretics are the preferred treatment for ascites and oedema in cirrhosis?

Answer 9

Aldosterone antagonists (potassium sparing diuretics) eg spironolactone.

Question 10

What diuretics are used as additional therapy in hypertension when it is not controlled by ACEI, CCB and thiazides?

Answer 10

Aldosterone antagonists (potassium sparing diuretics) eg spironolactone.

Question 11

What diuretics are used to treat hypertension caused by primary hyperaldosteronism?

Answer 11

Aldosterone antagonists (potassium sparing diuretics) eg spironolactone.

Question 12

What diuretics are used in conjunction with loop or thiazides diuretics to minimise K+ loss?

Answer 12

Epithelial Na+ channel blockers (potassium sparing diuretics) eg amiloride and triamterene.

Question 13

How would you manage a patient with stress urinary incontinence?

Answer 13

Pelvic floor muscle training.
Duloxetine as alternative to surgery.
Surgery: Females - permanent intention eg low-tension vaginal tapes, or temporary intention eg intramural bulking agents.
Males - artificial urinary sphincter or male sling procedure.

Question 14

How would you manage a patient with urge urinary incontinence?

Answer 14

Bladder training.
Anticholinergics eg oxybutynin.
Beta3-adrenoceptor agonist eg mirabegron.
If anticholinergics and beta3-adrenoreceptor agonists don’t work then use intravesical injection of botulinum toxin or surgery.
Surgery: sacral nerve neuromodulation, autooaugmentation, augmentation cystoplasty or urinary diversion.

Question 15

How would you manage incontinence conservatively?

Answer 15

General lifestyle interventions eg modify fluid intake, weight loss, stop smoking, decrease caffeine intake, timed voiding and avoid constipation.
Contained incontinence eg urethral or suprapubic catheter, sheath device (convene), incontinence pads.

Question 16

How would you manage a patient with goodpasture syndrome?

Answer 16

Immunosuppression and plasmapheresis if caught early.

Question 17

How would you manage a diabetic patient to prevent them developing a diabetic nephropathy?

Answer 17

Tight blood glucose control (<48mmol/mol) with multiple injections or insulin pump.
Right blood pressure control with any antihypertensive if normal albuminuria.
Possibly SGLT-2 inhibitors, not smoking and statin therapy help.

Question 18

How would you manage microalbuminuria and proteinuria in a patient with diabetes?

Answer 18

Inhibition of RAAS.
Tight BP control <130/75 mmHg.
Statin therapy.
CV risk management eg exercise, diet, stop smoking.
Moderate protein intake.
Tight blood glucose control may help.

Question 19

How would you manage a patient with nephrosclerosis?

Answer 19

Manage hypertension, with ACE-inhibitors or angiotensin-receptor blockers if there is albuminuria.

Question 20

How would you manage a patient with nephrotic syndrome?

Answer 20

Diuretics in large doses to manage oedema, give IV if gut oedema. Salt and fluid restriction.
ACE-inhibitor as is anti-proteinuric but be careful if patient is intravascularly deplete or if renal function is deteriorating acutely.
Treat hypercholesterolaemia.
Treat underlying condition eg steroids for medullary cystic disease.

Question 21

How would you manage a patient with nephrotic syndrome?

Answer 21

ACE-I or AIIR to control blood pressure and reduce proteinuria. Restrict salt.
Treat oedema with diuretics if adequate renal function eg large dose of loop diuretics with or without thiazides and a potassium-sparing diuretic/K+ supplements if K+ levels low.
Treat specific disease, generally with immunosuppressants eg for rapidly progressive glomerulonephritis give prednisolone, cyclophosphamide with or without plasma exchange.
CV risk management eg stop smoking, statins.

Question 22

How would you manage a patient with an uncomplicated UTI?

Answer 22

Increase fluid intake.
Address underlying disorders.
3 day course of trimethoprim or nitrofurantoin.
If a CSU only treat if systemically unwell.

Question 23

How would you manage a patient with a complicated UTI?

Answer 23

Increase fluid intake.
Address underlying disorders.
5-7 day course or trimethoprim, nitrofurantoin is cephalexin.
Post treatment follow up cultures in paediatric and pregnant patients.
CSU only treat if systemically unwell.

Question 24

What antibiotics are used to treat a patient with pyelonephritis/septicaemia?

Answer 24

14 day course of co-amoxiclav.
7 day course of ciprofloxacin.
IV initially unless food PO absorption and patient well enough.

Question 25

What antibiotics are used as UTI prophylaxis if 3 or more episodes within one year, with no treatable underlying condition?

Answer 25

Trimethoprim or nitrofurantoin.

As a single nightly dose. All breakthrough infections need documenting.

Question 26

What antibiotics are given to kidney transplant patients during the initial period after transplant to prevent infection?

Answer 26

Co-trimoxazole (pneumocystitis pneumoniae).
Valganciclovir (CMV).
Sometimes isoniazid for 6 months (TB).
Immunosuppressant for life.

Question 27

How would you manage a patient admitted with haematuria?

Answer 27

ABCDE and stabilise.
3 way catheter and irrigation.
Intervention eg cystoscope/interventional radiology if not settling.

Question 28

How would you manage a patient with renal stones?

Answer 28

Conservative management.
Non invasive - extracorporeal shockwave lithtotripsy.
Invasive - cystoscope with uteroscopy and lasertripsy or percutaneous nephrolithotomy.

Question 29

How would you manage a patient with ureteric stones?

Answer 29

<4mm 95% chance of passing within 3 weeks.
If painful then early stent, or primary uteroscopy and lasertripsy.
Usually stent and extracorporeal shock wave lithotripsy or uteroscopy and stone ablation.

Question 30

How would you manage a patient with AKI?

Answer 30

For volume overload - restrict dietary Na+ and water<1L/day.
For hyperkalaemia - calcium gluconate, restrict dietary K+, stop K-sparing diuretics, ACEi and ARB, exchange resin, dextrose and insulin, sodium bicarbonate if bicarbonate low, beta2 agonists.
For acidosis - NaHCO3- or dialysis where NaHCO3- not appropriate, and when high K+ or fluid overload resistant to treatment.

Question 31

How would you manage a patient with pre-renal AKI?

Answer 31

Fluid resuscitation.

Question 32

How would you manage a patient with localised renal cell carcinoma?

Answer 32

Surveillance.
Excision - radical nephrectomy or partial nephrectomy (open or laparoscopic).
Ablation - cryoablation or radiofrequency ablation.

Question 33

How would you manage a patient with metastatic renal cell carcinoma?

Answer 33

Palliative - biological therapied targeting angiogenesis eg sunitinib, sorafenib or pazopanib.

Question 34

How would you manage a patient with bladder transitional cell carcinoma?

Answer 34

Initially - transurethral resection and single intravesical instillation of mitomycin C.
Then - Intravesical chemotherapy, neoadjuvant chemotherapy, cystectomy, radiotherapy, intravesical immunotherapy.

Question 35

How would you manage a patient with a upper urinary tract transitional cell carcinoma?

Answer 35

Nephro-ureterectomy.

Question 36

How would you manage a patient with metastatic transitional cell carcinoma of the bladder or upper urinary tract?

Answer 36

Systemic chemotherapy - cisplatin-based.

Biological therapies - immunotherapy eg atezolizumab or pembrolizumab.

Question 37

How would you manage a patient with localised prostate cancer?

Answer 37

Surveillance.
Robotic radical prostatectomy.
Radiotherapy - external beam or brachytherapy.

Question 38

How would you manage a patient with locally advanced prostate cancer?

Answer 38

Surveillance.
Hormones.
Hormones and radiotherapy.

Question 39

How would you manage a patient with metastatic prostate cancer?

Answer 39

Hormones - with or without chemotherapy (surgical or medical castration - LHRH agonists).
Palliative care - single dose radiotherapy, bisphosphonates (zoledronic acid), chemotherapy (docetaxel) or new treatments (eg abiraterone and enzalutamide).

Question 40

How would you manage a patient within chronic kidney disease?

Answer 40

For hypertension - antihypertensive, diuretics (loop with or without thiazides but avoid K+ sparing diuretics) and fluid restriction.
For acidosis - oral NaHCO3 tablets.
For hyperkalemia - stop ACE-inhibitor/angiotensin receptor blocker, avoid drugs that can increase K+ (amiloride, spironolactone, trimethoprim), altering diet to avoid foods with high potassium.
For reduced drug metabolism/elimination - dose alteration.
For anaemia - replace iron (PO or IV), if haemoglobin still low, start erythropoietin stimulating agent.
For bone and mineral disorder - reduce phosphate intake, give phosphate binders (caution calcium), 1-alpha-calcidol and vitamin D.
For eGFR 8-10ml/min - renal replacement therapy (haemodialysis or peritoneal dialysis).
Transplant.

Question 41

How would you manage a patient with hyponatraemia?

Answer 41

ADH antagonist - tolvaptan.

Question 42

How would you manage a patient with decompensated liver disease?

Answer 42

Spironolactone.

Loop diuretics.

Question 43

How would you manage a patient with oedema that is not responding to treatment?

Answer 43

Check salt intake (can do 24 hours sodium excretion).
IV furosemide if gut oedema likely, but give minimum effective dose.
Give repeated bolus or infusion.

Question 44

How would you manage a patient with a testicular tumour?

Answer 44

Inguinal orchidectomy.

Question 45

How would you manage a patient with an epididymal cyst?

Answer 45

Reassure patient.

Excise if large.

Question 46

How would you manage an adult patient with a hydrocele?

Answer 46

If testis normal on USS then reassure.

Only surgically remove if large/symptomatic.

Question 47

How would you manage a patient with a varicocele?

Answer 47

Reassure.
Radiological embolisation is symptomatic, infertile, or if present in adolescence and the growth of the testis is affected.

Question 48

How would you manage a patient with an inguinal-scrotal hernia?

Answer 48

Surgery (emergency if strangulated).

Question 49

How would you manage a patient with epididymis-orchitis?

Answer 49

Antibiotics.

Question 50

How would you manage a patient with testicular abscess?

Answer 50

Surgical drainage and antibiotics.

Question 51

How would you manage a patient with Fournier’s gangrene?

Answer 51

Emergency debridement and antibiotics.

Question 52

How would you manage a male patient with acute urinary retention?

Answer 52

Catheterise and TWOC after addressing exacerbating factor.

Question 53

How would you manage a male patient with chronic urinary retention?

Answer 53

Teach to self catheterise.

Question 54

How would you manage a male patient with acute on chronic urinary retention?

Answer 54

TWOC (not usually successful and do not do if kidney insult).
Long-term catheter or surgical intervention.

Question 55

How would you manage a patient with benign prostatic hyperplasia?

Answer 55

Lifestyle modifications - reduce caffeine intake, avoid fizzy drinks, don’t drink more than 2.5L per day.
Alpha blockers eg tamsulosin.
5alpha-reductase inhibitors eg finasteride.
Surgery - transurethral resection of prostate.