Urinary and reproductive Flashcards
organisms causing UTIs in immunosuppressed (otherwise is E coli)
- klebsiella
- candida
- pseudomonas
- proteus vulgaris
when to do urine MC&S in UTI
- always in men
- > 65
- not required if symptomatic in non-pregnant women
- if failed to respond to treatment
- haematuria
when to do 2 week wait in UTI
- 45+ and unexplained visible haematuria
- 60+ and unexplained non-visible haematuria and dysuria/raised WCC
antibiotics to give in pyelonephritis (empirical before culture results)
oral ciprofloxacin 7-10 days
or co-amoxiclav 7 days
when to give antibiotic prophylaxis for pyelonephritis
- women with 3 symptomatic infections a year
- prophylaxis in children with VUR, recurrent infections or scarring on imaging
drugs causing prostatic acute urinary obstruction
- anticholinergics
- opioids
- alpha agonists
- benzos
- CCB
- NSAIDs
- TCAs
- antihistamines
what do you find in urinalysis in pyelonephritis
white cell casts in urine
what confirms diagnosis of prostatic acute urinary obstruction on bladder USS
> 300cc
what to offer 2 days before catheter removal in prostatic acute urinary obstruction
alpha blocker (then TWOC following alpha blocker commencement e.g. tamsulosin)
prostatic surgeries carried out for prostatic acute urinary obstruction
- TURP
- HoLEP (becoming more common)
long term medical treatment for BPH
- 5-alpha reductase inhibitors (finasteride)
- +/- alpha blockers
definition of severe hyperkalaemia
> 6.5
drugs causing hyperkalaemia
- ACEi
- ARBs
- spironolactone
- beta blockers
- LMWH
when is immediate treatment required for hyperkalaemia
- > 6 with ECG changes or
- >6.5
drugs used to treat hyperkalaemia
CIGS
- calcium gluconate IV (10ml 10%)
- insulin/dextrose infusion (10 units act rapid in 50ml 50% glucose over 20 mins)
- salbutamol nebs (5mg back to back over 10-20 mins)
also 15g oral calcium resonium/loop diuretics/dialysis to remove potassium from body
definite management of testicular torsion
immediate surgery = contralateral testis should also be fixed - 50% chance of torsion if not treated
when can you do expectant management of an ectopic
- if <30mm, unruptured, asymptomatic, no foetal heartbeat
- serum <200 and declining
closely monitor patient over 48 hours and perform intervention if hCG levels rise/symptoms then perform intervention
when can you do medical management of an ectopic
- hCG <1500 and falling
- if <35mm, unruptured, no pain, no foetal heartbeat
- not suitable if also an intrauterine pregnancy
medical management of ectopic
methotrexate IM - takes 4-6 weeks to completely resolve
how do recurrent attacks of genital herpes occur
reactivation of latent virus in sacral ganglia - may be triggered by:
- stress
- sex
- menstruation
gold standard diagnostic test for genital herpes
viral PCR of vesicle fluid
treatment of first episode of genital herpes
saline baths
lignocaine gel
analgesia
acyclovir 400mg TDS (need to start within 5 days)
some patients with frequent exacerbations may benefit from longer term acyclovir
what to do if first episode of genital herpes is in last stages of pregnancy (>28 weeks)
consider C/S to avoid dissemination (neurological effects/death)
test for HIV which can be done 3-4 weeks after infection
4th generation test - combination of antibody and antigen (p-24 antigen detected after 3-4 weeks but antibody takes 4-8 weeks to develop)
type of rash in HIV seroconversion illness (3-12 weeks after exposure)
maculopapular, on trunk
when does AIDs occur after infection with HIV
around 8 years after - death within 2 years without treatment
what is oral hairy leukoplakia indicative of
HIV
main indicator of risk of opportunistic infections in HIV
CD4 cell count
when do you start to get symptoms for CKD
stage 4 and 5 (otherwise often an incidental finding)
ACR levels and when to refer for CKD
if 3-70 repeat in 3 months
if >70 refer to nephrologist
what to do if eGFR <60
repeat within 2 weeks
criteria for diagnosis of CKD stages
- tests >3 months shown a reduction in kidney function or the presence of proteinuria
- eGFR is persistently <60 and/or urine ACR is persistently >3
do you have CKD if your eGFR is >60 and you have no other evidence of kidney damage
no - only stages 1 and 2 if:
1 = >90 and other evidence of damage
2 = 60-89 and other evidence of damage
BP targets for CKD
if ACR <70 - 140/90
if ACR >70 - 130/80
give ACEi to manage
medication to give in CKD
- ACEi
- atorvastatin 20mg
- anti platelet
- vaccines
avoid nephrotoxic drugs
criteria for detecting AKI
- rise in serum creatinine of 26+ in 48 hours
- 50% or greater rise in serum creatinine in past 7 days
- drop in urine output to 0.5ml/kg/hr for 6 hours in adults
when is RRT indicated in AKI
- pulmonary oedema
- persistent high potassium
- pH <7.15
- encephalopathy, pericarditis, drug overdose
if surgery is needed for stress incontinence what is carried out
tension-free vaginal tape (TVT)
triad of features in nephrotic syndrome
- proteinuria (>3)
- hypoalbuminaemia (<30)
- oedema
why can nephrotic syndrome result in thrombosis e.g. renal vein thrombosis
loss of antithrombin-III, proteins C and S and associated rise in fibrinogen
why does nephrotic syndrome increase the risk of infection
urinary immunoglobulin loss
why does nephrotic syndrome cause hypocalcaemia
vitamin D and binding protein lost in urine
management of non-muscle invasive bladder cancer
transurethral resection od bladder tumour
management of invasive bladder cancer
radical cystectomy/radiotherapy, neoadjuvant chemotherapy
genes associated with prostate cancer
BRCA2
pTEN
first line investigation for hydronephrosis
USS
treatment of acute vs chronic UUT obstruction
acute = nephrostomy tube
chronic = ureteric stent/pyeloplasty
why can renal carcinoma cause a varicocele
occlusion of left testicular vein
will U&Es always be abnormal in renal carcinoma
no - if one kidney is functioning well renal function will be normal
potential FBC findings of renal carcinoma
anaemia
polycythaemia (may secrete EPO)
most common site of mets of renal carcinoma
lungs - cannon ball secondaries is almost diagnostic
what can be used to reduce tumour size and treat mets in renal carcinoma
alpha interferon and interleukin 2
type of urinary stones associated with chronic infections
struvite stones
why does an ileostomy increase the risk of urinary stones
loss of bicarb and fluid = acidic urine = uric acid precipitation
type of diuretics which can increase the risk of and decrease the risk of urinary stones
loop diuretics can increase
thiazide diuretics can decrease calcium stones
imaging to do for urinary stones
CT KUB within 14 hours of admission (immediately if fever, solitary kidney or uncertain diagnosis - may need to exclude AAA)
drugs which can be used to facilitate stone passage
CCBs or alpha blockers
size of urinary stones which usually pass spontaneously
<5mm
can do lithotripsy, nephrolithotomy in severe cases
usually pass in 4 weeks
treatment of urinary stones 5mm-2cm
extracorporeal shock wave lithotripsy
if PREGNANT = uretoscopy
drugs to prevent uric acid stones
allopurinol
type of polycystic kidney disease presenting in childhood
recessive
dominant presents in adulthood
extra renal signs of ADPKD
- polycystic liver disease (reflux, dyspnoea, early satiety, haemorrhage)
- infertility in men
- pancreatitis
- aneurysms
imaging for urethral stricture
cystoscopy
diagnosis of VUR
micturating cystourethrogram
DMSA scan to look for renal scarring
4 types of glomerulonephritis
- minimal change (children, nephrotic syndrome)
- diffuse (all glomeruli)
- focal (only some glomeruli)
- segmental (parts of affected glomerulus)
type of glomerulonephritis which may be associated with HIV
focal
when to give PEP for HIV
anyone who has had unprotected sexual contact/condom failure with a high-risk source within last 72 hours
take for 28 days
high risk source = known HIV positive or unconfirmed HIV status but MSM, from country high HIV prevalence or IVDU
AIDS-related malignancies
- Kaposi’s sarcoma
- non-Hodgkin’s lymphoma
- invasive cervical carcinoma
all patients with non-Hodgkin’s lymphoma should be screened for HIV
what to give to newborn of HIV positive mother
PEP for 4 weeks after birth
gonorrhoea - type of bacteria
gram-negative diplococcus
treatment of gonorrhoea
ceftriaxone 500mg IM
hepatic consequence of gonorrhoea
perihepatitis
issues of gonorrhoea in pregnancy
- conjunctivitis within 3 days of birth
- can cause joint problems - rarely septicaemia
- preterm rupture of membranes
- chorioamnionitis
complications of chlamydia
- PID, endometritis, salpingitis
- tubal infertility
- ectopic pregnancy
- sexually acquired reactive arthritis (SARA)
- perihepatitis
what is Fitz-Hugh Curtis syndrome
perihepatitis due to chlamydia - infection reaches up around liver capsule
what are condylomata lata
painless warty lesions on genitalia - sign of secondary syphilis
type of rash in secondary syphilis
widespread mucocutaneoux
can affect palms and soles
neurological conditions in secondary syphilis
- acute meningitis
- cranial nerve palsies
- uveitis
- optic neuropathy
- delusions of grandeur
- interstitial keratitis and retinal involvement
features of neurosyphilis
tabes dorsalis
dementia
features of cardiovascular syphilis
aortic root
gummata
ascending aortic aneurysms
blood test for screening of syphilis
RPR test
what is a Jarisch Herxheimer reaction
reaction to treatment in syphilis - similar to anaphylaxis but no wheeze/hypotension
don’t need treatment - just antipyretics if needed
bacteria commonly causing acute bacterial prostatitis
- E. coli - gram negative bacteria entering prostate gland via urethra
- chlamydia
most consistent finding in chronic prostatitis
chronic pelvis pain
when to refer for prostatitis
diabetes
immunocompromised
pre-existing urological condition
chronic
antibiotics for acute prostatitis
14 days ciprofloxacin PO
infections associated with balanitis
strep and staph infections
candida in about 20%
what can circinate balanitis be associated with
reactive arthritis
investigations in balanitis
- DM testing (risk factor)
- swab of discharge
- STI testing
management of balanitis
- cleaning
- STI screening
- bacterial = fluclox
- candida = clotrimazole
- circumcision if recurrent/pathological phimosis present
what is phimosis vs paraphimosis
phimosis = foreskin can’t be retracted
paraphimosis = foreskin pulled back but can’t be returned to original position
what is balanitis xerotica obliterans associated with
whitish plaque on glans - associated with phimosis in adults
most common cause of paraphymosis
not replacing foreskin after inserting catheter
complication of paraphymosis
ischaemia of glans (if not treated)
drugs which can cause erectile dysfunction
SSRIs
beta blocker
management of erectile disjunction
- control risk factors (weight, smoking, alcohol)
- PDE-5 inhibitors (viagra)
what type of drug is sildenafil
viagra - PDE-5 inhibitor
common cause of epididymo-orchitis in people <35
gonorrhoea
other causes = mumps, UTI, trichomoniasis, HIV, TB
drug which can cause epididymo-orchitis
amiodarone
treatment of epididymo-orchitis if caused by gonorrhoea
treat as for gonorrhoea
treatment of epididymo-orchitis if caused by enteric bacteria (e.g. E. coli)
ofloxacin
what are elevated in testicular germ cell tumours (cancer)
AFP elevated in 60%
LDH elevated in 40%
most common type of breast cancer
infiltrating/invasive ductal carcinoma
when to do BRCA1/BRCA2 testing in someone with breast cancer
women under 50
triple negative breast cancer (ER/PR/HER2)
what to do about lymph nodes during surgery for breast cancer
- if axillary node involvement = axillary clearance
- if no evidence of involvement = sentinel node biopsy
when to do neoadjuvant chemotherapy for breast cancer
- initial surgery not possible due to tumour size
- to allow for breast conservation
- HER2 positive or triple negative
when to give hormonal therapy to people with breast cancer
in ER/PR positive disease = Tamoxifen
in HER2 positive disease = Herceptin (trastuzumab)
aromatase inhibitors = superior efficacy to tamoxifen in post-menopausal women
complication of using tamoxifen
increases risk of endometrial cancer
risk factor for breast fibroadenoma
HRT
investigation for fibroadenoma
triple assessment:
- examination (USS if <40, mammogram if older)
- needle biopsy (might not be required)
when to do a biopsy in fibroadenoma
> 4cm - core biopsy to exclude phyllodes tumour
when to consider a breast abscess
if infection doesn’t clear after 1 course of antibiotics - therefore would need to incise and drain with antibiotics
how to diagnose adenomyosis
MRI
antibiotics for PID
doxycycline
ceftriaxone
metronidazole
what to give to partner of someone with PID
doxycycline
OR ofloxacin and metronidazole
what can lichen sclerosus et atrophicus develop into
vulval carcinoma
most common type vulval cancer
squamous cell
what size ovarian cyst should have yearly USS follow up
5-7cm
> 7cm = consider MRI
when to do a laparoscopic cystectomy for an ovarian cyst
> 10cm, solid or complex, fixed, bilateral, ascites
moat common type of ovarian cyst
follicular (physiological)
what can cause pseudomyxoma peritonea
if a mutinous cystadenoma ruptures
type of ovarian cyst associated with Meig’s syndrome (benign ovarian cyst, pleural effusion, ascites)
fibromas
what can cause a haemorrhagic degeneration of fibroids
progestins
clomifene
pregnancy
potential renal complication of fibroids
hydronephrosis
what can be used to temporarily shrink fibroids
GnRH agonists
pH of discharge in trichomoniasis
> 4.5
management of mycoplasma genitalium
azithromycin
moxifloxacin
penicillins WONT work as no cell walls
pH of discharge in BV
> 4.5 (same as trichomoniasis)
pH of discharge in candida
<4.5
what can you find on histology in BV
clue cells
management of bacterial vaginosis
metronidazole
medical management of miscarriage
mifepristone - misoprostol 2 days later
LH and FSH levels in PCOS
LH chronically elevated
FSH chronically suppressed
Rotterdam criteria for PCOS
2/3 required of:
- polycystic ovaries (12+ follicles or ovarian volume >10cm3 on USS)
- hyperandrogegism
- oligo/anovulaiton
prolactin level in PCOS
normal
when can undescended testes increase the risk of testicular cancer
if intra-abdominal - risk of malignant degeneration
at what age should undescended testes be considered
from 3 months old - unlikely to descend spontaneously from 6 months old
majority of surgeries performed around 1 year
