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Year 5 Core Conditions > Urinary System - Level 2 > Flashcards

Urinary System - Level 2 Flashcards

1
Q

Definition of CKD?

A
  • Abnormal kidney function or structure present for >3 months or eGFR <60
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2
Q

Normal functions of kidney?

A

Excretory –
 inorganic substances (e.g. potassium, phosphate)
 organic (urea, creatinine)
 clinically “uraemic toxicity”

Homeostasis – fluid balance, blood pressure, acid-base

Endocrine – erythropoietin, bone metabolism

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3
Q

Epidemiology of CKD?

A
  • Over 70% due to DM, hypertension
  • Prevalence increases with age
  • 8.5% Stage 3-5 CKD
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4
Q

Causes of CKD - intrinsic?

A

o Hypertension
o DM (Type 2 most common)
o Glomerulonephritis
o Renal artery stenosis

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5
Q

Causes of CKD - nephrotoxic?

A

o NSAIDs, Lithium, Ciclosporin, Tacrolimus, Aminoglycosides, Mesalazine

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6
Q

Causes of CKD - obstructive?

A

o Bladder voiding dysfunction
o Urinary diversion surgery
o Recurrent urinary stones

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7
Q

Causes of CKD - multi-system disease?

A

o SLE, vasculitis, myeloma, polycystic kidney disease, Alport’s syndrome

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8
Q

Symptoms of CKD?

A
  • Asymptomatic at first
  • Anaemia – Low EPO – Pallor, SOB
  • Renal osteodystrophy – osteomalacia, bone pain
  • Epistaxis/bruising
  • Uraemic symptoms
  • Anorexia/nausea/vomiting
  • Restless legs, weakness, pruritus and bone pain
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9
Q

Signs of CKD?

A
  • Pallor, uraemic tinge, purpura, increased BP, signs of fluid overload, ballotable kidneys
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10
Q

When to test people for CKD?

A

Test people with risk factors for CKD:
o Diabetes, hypertension, AKI, CVD, SLE, structural renal tract disease, recurrent calculi, BPH
o Family history of CKD stage 5
o Taking nephrotoxic drugs (ciclosporin, tacrolimus, lithium, NSAIDs)

Test people with incidental findings:
o Proteinuria or persistent haematuria (2/3 with 1+) after exclusion of UTI
o eGFR of <60

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11
Q

What tests to perform in people suspecting CKD?

A
  • Serum creatinine (eGFR)
  • Early Morning Urine – Albumin Creatinine Ratio (ACR)
  • Urine dipstick for haematuria
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12
Q

Specific advice for testing eGFR in CKD?

A

o No meat in 12 hours before, caution if extreme muscle mass
o Confirm result if <60 with test 2 weeks later
o If stable but same, repeat 3 months

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13
Q

Specific advice for testing EMU ACR in CKD?

A
  • Early Morning Urine – Albumin Creatinine Ratio (ACR)
    o Repeat if 3-70mg/mmol within 3 months, no need if >70
    o >3 is clinically proteinuria
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14
Q

Specific advice for testing urine dipstick in CKD?

A

o Significant haematuria if 1+ or more, exclude UTI by sending MSU

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15
Q

Specific advice for testing renal USS in CKD?

A

o If accelerated progression of CKD, visible or persistent invisible haematuria, symptoms of UT obstruction, FHx of PKD and >20 years, eGFR <30

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16
Q

Other tests to find cause of CKD?

A
  • Bloods (low Hb, Ca, high PO4 and ALP and PTH, glucose, U&Es)
  • Urine – ACR, dipstick
  • USS to check kidneys size and anatomy
  • Renal biopsy if rapid decline and cause unclear
  • Immunology – Goodpasture’s syndrome, IgA nephropathy
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17
Q

Diagnosis of CKD can be made when?

A
  • EGFR <60 and/or ACR >3 after 3 months
  • If repeat eGFR 45-59 and urine ACR <3 and no proteinuria:
    o Use eGFRcystatinC test
     Hypothyroidism elevates, hyperthyroidism reduces
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18
Q

Classification of CKD stages?

A
  • Stage 1 - >90 No impairment
  • Stage 2 – 89-60 Slight
  • Stage 3A – 59-45 Moderate
  • Stage 3B – 44-30 Severe
  • Stage 4 – 29-15 Severe
  • Stage 5 - <15 Renal Failure
  • ACR classified in each stage as A1 - <3, A2 – 3-30, A3 - >30
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19
Q

When to refer CKD to nephrologist?

A
  • eGFR <30
  • ACR >70mg/mmol
  • ACR >30mg/mmol with haematuria
  • Decrease by >25% in year or decrease GFR >15ml/min/1.73 in year
  • Poorly controlled BP on 4 antihypertensives
  • Suspected genetic causes or renal artery stenosis
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20
Q

Monitoring of CKD?

A
  • Annual eGFR and ACR if no CKD and risk factors
  • eGFR, ACR (stage 1-3a annually, stage 3b-4 biannually, stage 5 quarterly)
  • FBC (Stage 3b, 4, 5)
  • Serum calcium, phosphate, vitamin D and PTH in (stage 4, 5)
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21
Q

Management of CKD - self-management?

A
  • Stop smoking
  • Regular exercise and healthy body weight
  • Eat healthy diet – low sodium, Vit D analogues and Ca supplements
  • Avoid NSAIDs, nephrotoxics
  • Manage and minimise risk factors
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22
Q

Management of CKD - antihypertensives?

A

o If hypertensive and ACR <30 – follow guidelines

o If hypertension and ACR >30 – ACEi/ARB

o If ACR >70 and normotensive OR CKD and diabetic – ACEi/ARB (aim <130/80)

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23
Q

Management of CKD -aim of antihypertensives?

A

Aim <140/90 in hypertensive + CKD + ACR <70

Aim <130/80 in ACR>70 + normotensive or CKD + diabetes

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24
Q

Management of CKD -monitoring of antihypertensives?

A

 Measure serum potassium and eGFR before ACEi, 1-2 weeks later and at any dose change (before starting K<5, otherwise don’t start ACE/ARB, stop if K>6 after 1-2 weeks)
 If eGFR decreased by >25% then repeat test 1-2 weeks – if <25% then continue and repeat test in 1-2 weeks, if >25% investigate causes and stop drug

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25
Q

Management of CKD - statin therapy?

A
  • Atorvastatin 20mg daily (if eGFR <60 and ACR >3)
    o Baseline lipids, CK, LFTs
    o Can increase dose if not >40% reduction in non-HDL cholesterol and eGFR >30 in 3 months
    o Repeat lipids at 3 months
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26
Q

Management of CKD -antiplatelets and anticoagulants?

A
  • Antiplatelets
    o Secondary prevention only
  • Anticoagulant
    o Secondary prevention of CVD – Apixaban used if eGFR 30-50 and non-valvular AF and 1 of: Hx of TIA/stroke, >75, HTN, DM, HF
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27
Q

Management of CKD - complications - anaemia?

A

o Check Hb in people with eGFR <45
o Offer iron tablet if deficient – if Hb level not reached within 3 months, offer IV therapy
o If on dialysis – offer IV iron first
o EPO may be needed

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28
Q

Management of CKD - complications - bone complications?

A

o Measure serum Ca, phosphate, PTH and Vit D when eGFR <30
 If needed – cholecalciferol

o Bisphosphonates for prevention of osteoporosis when eGFR >30, if indicated only

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29
Q

Management of CKD - complications - bicarbonate level?

A
  • Oral sodium bicarbonate

o eGFR<30 or sodium bicarbonate <20

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30
Q

Definition of deterioration of CKD?

A
  • Decrease by >25% or 15ml/min/1.73 in year
  • Repeat eGFR 3x over 90 days
  • Refer to nephrologist as before
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31
Q

When to discuss RRT in CKD?

A
  • Discuss when eGFR <20
  • Dialysis started when impact of symptoms of uraemia on daily living, biochemical measures or uncontrollable fluid overload or at eGFR around 5-7 if no symptoms
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32
Q

Options of RRT in CKD?

A
  • Haemodialysis
    o Diffusion solutes between blood and dialysis fluid – access via fistula inserted 6 months before start
  • Peritoneal dialysis
    o Diffusion solutes between blood in peritoneal capillaries and dialysis fluid in peritoneal cavity
    o Continuous ambulatory peritoneal dialysis (4x a day)
    o Automated PD (several exchanges per night)
  • Kidney transplant
    o From deceased donor or live donor
    o Lifelong immunosuppression
    o Must be medically fit for surgery
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33
Q

Prognosis of CKD?

A
  • CKD progresses to End-stage KD in 2% of people

- 20x more likely to die of CVD then to progress to End-stage KD

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34
Q

Complications of CKD?

A
  • Renal replacement therapy
  • CVD and events
  • Renal anaemia, bone disease (low Ca, high PO4 and PTH)
  • Malnutrition
  • Neuropathy
  • Lipid abnormalities
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35
Q

Definition of AKI?

A
  • Rapid reduction in kidney function over hours to days, as measured by serum urea and creatinine – leading to failure to maintain fluid, electrolyte and acid-base homeostasis
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36
Q

Epidemiology of AKI?

A
  • Occurs in 18% of hospital patients
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37
Q

Risk factors of AKI?

A
  • Age>75
  • CKD
  • Cardiac failure
  • PVD
  • Liver failure
  • Diabetes
  • Drugs
  • Sepsis
  • Poor fluid intake
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38
Q

Causes of AKI - pre-renal?

A

Most common

o Renal hypoperfusion due to hypotension (hypovolaemia, D&V, sepsis), renal artery stenosis +/- ACEi
o Reduced cardiac output (cardiac and liver failure)

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39
Q

Causes of AKI -intrinsic?

A

10-50%

o	Acute tubular necrosis
	Due to drugs, aminoglycosides, radiological contrast, rhabdomyolysis
o	Glomerulonephritis
o	Vasculitis, thrombosis
o	Interstitial nephritis, lymphoma
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40
Q

Causes of AKI - post-renal?

A

10-25%

Urinary tract obstruction
 Luminal – stones, clots
 Mural – malignancy, BPH, strictures
 Extrinsic compression – malignancy, retroperitoneal fibrosis

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41
Q

Symptoms and signs of AKI?

A
  • May be none
  • Fatigue, malaise, rash
  • Joint pains, nausea and vomiting
  • Chest pain, palpitations, SOB, fluid overload
  • Oliguria, hypo/hypertension
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42
Q

When to measure U&Es to identify AKI?

A

 CKD, HF, liver disease, Hx of AKI, oliguria (<0.5ml/kg/hour), hypovolaemic, NSAIDs, ACEi/ARBs, diuretics, urinary obstruction, sepsis, severe diarrhoea, nephritis, hypotension, >65

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43
Q

When to detect AKI in hosptial patients?

A

 Rise in serum creatinine >26 within 48 hours
 50% or greater rise in serum creatinine within 7 days
 Fall in urine output to <0.5ml/kg/hour for >6 hours in adults and >8 hours in children
 25% or greater fall in eGFR in children and young people within 7 days

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44
Q

KDIGO staging of AKI - Stage 1?

A
  • Rise in creatinine >26umol/L in 48h OR >1.5-1.9x baseline (best figure in last 3 months)
  • Urine output <0.5ml/kg/h for >6 consecutive hours
45
Q

KDIGO staging of AKI - Stage 2?

A
  • Increase in creatinine 2-2.9x baseline

* Urine output <0.5ml/kg/h for >12h

46
Q

KDIGO staging of AKI - Stage 3?

A
  • Increase in creatinine >3x baseline OR >354umol/L OR commenced on RRT
  • Urine output <0.3ml/kg/h for >24h OR anuria for >12h
47
Q

Tests to identify cause of AKI?

A

Bloods
• FBC, U&E, LFTs, Ca, Phosphate
• Cultures if signs of infection

Urinalysis
• Test for blood, protein, leucocytes, nitrites and glucose as soon as suspected
• If haematuria and proteinuria and no obvious cause/UTI/trauma – think acute nephritis

Ultrasound
• Do not offer if cause of AKI identified
• If pyonephrosis suspected – US within 6 hours
• If no cause of AKI found – urgent US within 24 hours

48
Q

Management of AKI - if urinary obstruction suspected/identified?

A

Refer immediately when one or more of following is present:
 Pyonephrosis
 Obstructed solitary kidney
 Bilateral upper urinary tract obstruction
 Complications of AKI caused by urological obstruction

Nephrostomy or stenting performed within 12 hours of diagnosis if needed

49
Q

Management of AKI -investigations to perform?

A

o ABG/VBG
o ECG
o Catheterisation and urine output

50
Q

Management of AKI - initial management - STOP AKI?

A

Sepsis
 Complete sepsis 6 if sepsis suspected

Toxins
 Stop/avoid nephrotoxics (Gentamicin, NSAIDs, ACE/ARBs, diuretics, contrast)

Optimise BP
 If low BP – fluid bolus (0.9% saline 500ml IV 15-20 minutes)

Assess volume status
 BP, JVP, skin turgor, fluid balance sheet, weight
 IV fluids
• If low BP – fluid bolus (0.9% saline 500ml IV 15-20 minutes)
• IV fluids maintenance if not hypovolaemic

Prevent Harm
	Treat complications
•	Hyperkalaemia
•	Pulmonary oedema
•	Acidosis
•	Pericarditis
	Review all medications
	Identify cause

Refer to renal team early for opinion

51
Q

Management of AKI - monitoring?

A

o Check pulse, BP, JVP, urine output hourly
o CVP line if on HDU/ICU
o Daily U&Es, fluid balance chart and daily weight

52
Q

Management of AKI - when to discuss with nephrology?

A 
	Specialist treatment needed (vasculitis, glomerulonephritis, nephritis, myeloma)
	AKI with no clear cause
	Inadequate response to treatment
	Complications associated
	Stage 3 AKI
	Renal transplant
	CKD Stage 4/5
53
Q

Management of AKI -indications for RRT?

A

o Refractory pulmonary oedema
o Persistent hyperkalaemia
o Severe metabolic acidosis (7.15)
o Ureamic complications (pericarditis, encephalopathy)
o Drug overdose – Barbituates, lithium, alcohol, salicylates, theophylline

54
Q

Options for RRT in AKI?

A

Haemodialysis
 Blood passed over semi-permeable membrane against dialysis fluid flowing in opposite direction

Hemofiltration
 Water is cleared across dialysis membrane using positive pressure to drag small and larger size solutes into waste by convection

Peritoneal Dialysis
 Uses peritoneum as semi-permeable membrane and allows solutes to diffuse slowly
 Can be performed continuously and at home so allows more freedom

55
Q

Follow up after AKI?

A

o Monitor U&Es for 2-3 years after AKI

56
Q

Complications of AKI?

A
  • Hyperkalaemia
  • Metabolic acidosis
  • Volume overload
  • Uraemia
  • CKD
57
Q

Symptoms in urinary incontinence?

A

Stress - leakage of urine on sneezing, coughing, exercise, rising from sitting or lifting

Urge - urgency and failure to reach toilet, frequency and nocturia possible

Other symptoms to ask:
Frequency during day/night, dysuria, haematuria,, dribbling of urine after leaving toilet, feeling incomplete bladder emptying

58
Q

Gynaecological history important in urinary incontinence?

A 
Uterus or not
Pre/Postmenopausal
Problems with intercourse
How many babies - delivery method
Smear tests up to date
59
Q

PMH important in urinary incontinence?

A 
Uterus or not
Pre/Postmenopausal
Problems with intercourse
How many babies - delivery method
Smear tests up to date
60
Q

DH important in urinary incontinence?

A

Diuretics
Laxatives
Medications for urinary symptoms in past

61
Q

SH for urinary incontinence?

A 
Caffeine intake
Carbonated drinks
Alcohol
Smoking
Ketamine
Occupation - heavy lifting?
62
Q

Examination performed in incontinence?

A 
History including obstetric, sexual and functional status
BMI and Urine dipstick &amp; MSU
Abdominal and pelvic examination
Cough - any leakage?
Assess for prolapse
Assess for vaginal atrophy
VE
Smear
63
Q

Investigations in urinary incontinence?

A
  • Urinalysis and MSU microscopy (culture and sensitivity)
    o Exclude UTI
  • OGTT if diabetes suspected
  • Frequency/volume chart
    o Should be filled in for 72h and give idea off fluid intake and voiding problems
64
Q

When should a cystoscopy be performed in urinary incontinence?

A

o Used to visualise urinary tract

o Indicated if recurrent UTI, haematuria, bladder pain, suspected fistula, tumour

65
Q

What are the specialist tests performed for urinary incontinence?How do they work?

A

Urodynamics

o Uroflowmetry
Ability of bladder to store and void urine
Patient voids in private onto commode with urinary flow meter, measuring voided volume over time and plotting graph
o Cystometry
Invasive and involves measuring pressure and volume in bladder during filling and voiding
Bladder filled with saline and intravesical & vaginal/rectal probe measure differences in pressure to give detrusor pressure
Patient first desire to void, strong desire to void and cough
Diagnoses stress incontinence

66
Q

Initial management of stress urinary incontinence?

A 
Lifestyle interventions
•	Weight reduction if BMI >30
•	Smoking cessation
•	Reduce caffeine and fizzy drinks
•	Treatment of chronic cough and constipation

Pelvic floor muscle training
• For at least 3 months
• Exercises continued long-term.
• 8-12 slow maximal contractions sustained for 6-8 seconds each, 3x per day

Follow up 3 months

67
Q

Follow up management of stress urinary incontinence?

A

Urodynamics

MDT Meeting

Duloxetine
• SNRI enhances urethral striated sphincter activity via a centrally mediated pathway.
• Dose-dependent decreases in frequency of incontinence episodes

Transvaginal tape

68
Q

Pharmacological management of stress urinary incontinence?

A

Duloxetine
• SNRI enhances urethral striated sphincter activity via a centrally mediated pathway.
• Dose-dependent decreases in frequency of incontinence episodes

69
Q

Surgical management of stress urinary incontinence ? When considered and what types?

A

Considered when other measures failed

Transvaginal Tape
• Polypropylene mesh tape placed under mid-urethra via small vaginal incision
• Risks – bladder injury, voiding difficulty, tape erosion

Periuretheral injections
• Bulking agents, better for older, frail or young women

70
Q

Initial management of urge urinary incontinence?

A

Lifestyle advice
• Weight reduction if BMI >30, smoking cessation, reduce caffeine and fizzy drinks, treatment chronic cough and constipation

Pelvic floor muscle training
• 3 months, exercises continued long-term, 8-12 slow maximal contractions sustained for 6-8 seconds each, 3x per day

Bladder diary (>3 days) - idea of fluid intake and bladder voiding problems

Bladder drills
• Ability to suppress urinary urge and extend the intervals between voiding

Anticholinergics - Oxybutynin (+/- vaginal oestrogen if vaginal atrophy)

Follow up 3 months

71
Q

Describe properties of initial pharmacological management of urge urinary incontinence? SE? CI?

When is botox used?

A

Anticholinergic (antimuscarinic) agents (oxybutynin)
• Block the sympathetic nerves thereby relaxing the detrusor muscle
• Side effects = dry mouth (up to 30%), constipation, nausea, dyspepsia, flatulence, blurred vision, dizziness, insomnia, palpitation, arrhythmias.
• Contraindications = acute (narrow angle) glaucoma, myaesthenia gravis, urinary retention or outflow obstruction, severe UC, GI obstruction.

Oestrogens
• In women with vaginal atrophy, intravaginal oestrogens may be tried

Botulinum Toxin A
• Blocks neuromuscular transmission – causing the muscle to become weak.
• Used in follow up and injected cystoscopically into the detrusor, usually under local anaesthetic.

72
Q

Follow up management of urge urinary incontinence?

A

Try 2nd anticholinergic (tolterodine)

Urodynamic study (increased detrusor pressure upon voiding)

MDT meeting

Cystoscopy & Botox (botulinum toxin A)

Nerve stimulation - percutaneous posterior nerve/percutaneous sacral nerve

Augmentation cystoplasty - if small bladder

Urinary diversion

73
Q

Management of overflow incontinence?

A

o Treat with catheter
• Can cause urinary retention in 5-20% of cases, in which intermittent self catherterisation may be required.
o Surgical
 Reserved as last resort for debilitating symptoms, failed therapies
 Bladder distension, sacral neuromodulation, detrusor myomectomy have limited efficacy

74
Q

How common is urogenital prolapse?

A
  • Occurs in 40-60% of parous women

* Most common reason postmenopausal women have hysterectomy

75
Q

Definition of urogenital prolapse?

A

o Weakness of supporting structures (levator ani muscles and endopelvic fascia) allows the pelvic organs to protrude within the vagina
o Can be bladder, urethra, rectum, and bowel

76
Q

Risk factors of urogenital prolapse?

A 
o	Increasing age
o	Vaginal delivery
o	Increasing parity
o	Obesity
o	FHx of prolapse
o	Constipation/Chronic cough
77
Q

Types of urogenital prolapse?

A

o Can occur in anterior, middle or posterior compartments of pelvis

78
Q

Anterior types of urogenital prolapse?

A 
	Cystocele
•	Prolapse of bladder into the vagina
	Urethrocele
•	Prolapse of urethra into the vagina, associated with USI
	Cysto-urethrocele when both (MC)
79
Q

Middle types of of urogenital prolapse?

A

 Uterine prolapse
• Descent of uterus into vagina
• Baden-Walker Graded

 Vaginal vault prolapse
• Descent of vaginal vault post-hysterectomy, associated cystocele, rectocele and enterocele common

 Enterocele
• Herniation of pouch of Douglas into vagina
• Pouch usually contains loops of small bowel

80
Q

Posterior types of urogenital prolapse?

A

 Rectocele

• Prolapse of rectum into vagina

81
Q

POPQ staging of urogenital prolapse?

A

o 0 = No prolapse
o 1 = >1cm above hymen
o 2 = At level of hymen
o 3 = >1cm below hymen but protrudes <2cm total length of vagina
o 4 = Complete eversion of vagina (complete procidentia)

82
Q

General symptoms of urogenital prolapse?

A
  • Dragging sensation discomfort, and heaviness within the pelvis.
     Usually worse at the end of the day or when standing up.
  • Feeling of ‘a lump coming down’
  • Dyspareunia or difficulty in inserting tampons.
  • Discomfort and backache.
83
Q

Cysto-urethrocele symptoms of urogenital prolapse?

A
  • Urinary urgency and frequency.
  • Incontinence
  • Incomplete bladder emptying
    o Urinary retention or reduced flow where the urethra kinked
84
Q

Rectocele symptoms of urogenital prolapse?

A
  • Constipation

- Difficulty with defecation (may digitally reduce it to defecate).

85
Q

Other symptoms of urogenital prolapse?

A
  • Symptoms tend to become worse with prolonged standing and towards the end of the day.
  • Grade 3 or 4 prolapse, there may be mucosal ulceration and lichenification, resulting in vaginal bleeding and discharge.
  • Symptoms can affect quality of life, causing social, psychological, occupational or sexual limitations to a woman’s lifestyle.
86
Q

Examinations performed in urogenital prolapse?

A

• Examine patient in both standing and left lateral position
o Ask woman to strain and observe
• Bimanual examination (exclude pelvic masses)
• Sims speculum examination
o Inspect anterior and posterior walls, ask to strain

87
Q

Investigations of urogenital prolapse?

A
  • USS to exclude pelvic or abdominal masses.
  • Urodynamics are required if urinary incontinence is present
  • Assess fitness for surgery – ECG, CXR, FBC, U&Es
88
Q

Prevention of urogenital prolapse?

Conservative management of urogenital prolapse?

A

Prevention

  • Reduction of prolonged labour, trauma caused by instrumental delivery
  • Encouraging persistence with post-natal pelvic floor exercises.

General Advice

  • Weight reduction
  • Avoid heavy lifting
  • Treatment of chronic constipation and cough (including smoking cessation)
  • Pelvic floor muscle exercises
89
Q

Further management of urogenital prolapse - Intravaginal (pessary) devices? When used? What is it? Instructions?

A
  • Conservative line of therapy for women who decline surgery, who are unfit for surgery, or for whom surgery is contraindicated.

o Artificial pelvic floor placed in the vagina to stay behind the symphysis pubic and in front of the sacrum.

o Sexually active women can use ring pessaries, either have sex with it in place or take it out and replace after

o They should be changed 6 monthly and if post-menopausal, topical oestrogen may be given to decrease risk of vaginal erosion.

90
Q

Types of pessary and when used?

A

Ring pessary = most commonly used
o Placed between the posterior aspect of the symphysis pubis and posterior fornix of the vagina.

Shelf pessary = used when a correctly sized ring pessary will not sit in the vagina and/or where the perineum is deficient

Others: Hodge pessary, cube and doughnut pessaries (very rarely used).

91
Q

Indications for surgical management of urogenital prolapse?

A
  • Failure of conservative treatment
  • Voiding or defaecation problems
  • Recurrent prolapse after surgery
  • Ulceration
  • Irreducible prolapse
  • Preference
92
Q

Surgical management of anterior compartment of urogenital prolapse?

A

• Anterior colporrhaphy (anterior repair)

- Appropriate for repair of a cysto-urethrocele.

93
Q

Surgical management of posterior compartment of urogenital prolapse?

A 
Posterior colporrhaphy (posterior repair)
-	Appropriate for correction of a rectocele and deficient perineum
94
Q

Surgical management of uterovaginal (apical) compartment of urogenital prolapse?

A
  • Vaginal hysterectomy (most common)
  • Sacrohysteropexy
  • Preserve the uterus.
  • Attaches the prolapsed uterus to the sacrum
95
Q

Surgical management of vaginal vault of urogenital prolapse?

A

• Sacrospinous ligament fixation

- Suturing vaginal vault to sacrospinous ligaments using a vaginal approach.

96
Q

Surgical management of recurrent compartment of urogenital prolapse?

A
  • ~1/3 of prolapse surgery is for recurrent prolapse.
  • Vaginal epithelium may be scarred and atrophic (makes surgery harder and gives increased risk of damage to bladder and bowel)
97
Q

Surgical management of recurrent compartment of urogenital prolapse?

A
  • ~1/3 of prolapse surgery is for recurrent prolapse.
  • Vaginal epithelium may be scarred and atrophic (makes surgery harder and gives increased risk of damage to bladder and bowel)
98
Q

Definition of nephrotic syndrome?

A 
-	Clinical syndrome defined as:
o	Proteinuria (>3.5g/24h (ACR>250))
o	Oedema
o	Hypoalbuminemia (<30g/L)
  • It is caused by injury to podocyte which increase permeability of serum protein through the damaged basement membrane in the renal glomerulus
99
Q

Classes of nephrotic syndrome?

A
  • Classified as steroid sensitive, steroid resistant or steroid dependent
100
Q

Aetiology of nephrotic syndrome - primary?

A

Minimal change disease – 85% in children
• Idiopathic, NSAIDs, Hodgkin’s lymphoma
• Biopsy – normal under light microscopy
• Steroids usual course of treatment

Focal segmental glomerulonephritis (FSGN) – most common in adults
• Segmental areas of mesangial collapse and sclerosis
• Due idiopathic, HIV, SCD, Alport’s, obesity, reflux nephropathy

Membranous nephropathy – common in older adults
• Due to – malignancy, hepatitis B, gold, penicillamine, NSAIDs, thyroid, SLE
• Thickened GBM

Membranoproliferative glomerulonephritis

101
Q

Aetiology of nephrotic syndrome - secondary?

A

 Infection – HIV, HepB/C, syphilis, malaria
 SLE, HSP, Lupus
 Diabetes – MC secondary cause
 Alport’s syndrome
 Malignancies
 Toxins (snake bites, bee stings) and heavy metals

102
Q

Symptoms and signs of nephrotic syndrome?

A
  • Periorbital oedema, leg/ankle oedema, ascites and breathlessness
  • Oliguria
  • Proteinuria, oedema, hypoalbuminemia
  • Dyslipidaemia, abnormalities in coagulation/fibrinolysis, reduced renal function
103
Q

Investigations of nephrotic syndrome?

A

Urine dipstick
o Check for protein & microscopic haematuria

Urine MSU
o Microscopy, culture and sensitivities to exclude UTI
 Red cell casts, protein electrophoresis

Urine ACR

Bloods
o FBC, CRP, ESR, U&E’s (creatinine, low albumin)
o Complement levels
o Autoimmune screen – ANA, ANCA, anti-DNA, anti-GBM, complement)
o Syphilis/HepB/C screen

CXR and renal USS

Renal biopsy

104
Q

Management of nephrotic syndrome - general advice?

A
  • Sodium and fluid restriction
  • High-dose loop diuretics (furosemide)
  • Daily weight & U&Es
  • Pneumococcal and influenza vaccination
105
Q

Management of nephrotic syndrome - minimal change disease

A

Steroid-sensitive nephrotic syndrome
 Oral prednisolone for 4 weeks then wean over 4 months
• If steroid toxicity, use cyclophosphamide

Steroid-resistant nephrotic syndrome
 Management of oedema with diuretics, salt restriction and ACE inhibitors (enalapril)

106
Q

Management of nephrotic syndrome - focal segmental glomerulonephritis?

A

o Corticosteroids

o Cyclophosphamide if steroid-resistant

107
Q

Management of nephrotic syndrome - membranous nephropathy?

A

o Secondary – treat cause

o ACEi and diuretics

108
Q

Management of nephrotic syndrome - mesangiocapillary GN?

A

o ACEi

o Steroids and cyclophosphamide if rapid deterioration

109
Q

Complications of nephrotic syndrome ?

A
  • Susceptible to infections
  • Risk of VTE – urinary excretion of antithrombin 3
  • Hyperlipidaemia
  • AKI/CKD

Year 5 Core Conditions (55 decks)

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