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Renal and Uro > uro > Flashcards

uro Flashcards

1
Q

definition of obstructive uropathy

A

problem passing urine as a result of an obstruction along the urinary tract

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2
Q

presentation of upper urinary tract obstruction (ureters)

A
  • loin to groin/flank pain on affected side
  • reduced/no urine output
  • non-specific symptoms such as vomiting
  • reduced renal function on bloods
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3
Q

presentation of lower urinary tract obstruction (bladder/urethra)

A
  • acute urinary retention
  • lower urinary tract symptoms: poor flow, difficulty initiating urination, terminal dribbling)
  • reduced renal function on bloods
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4
Q

3 causes of upper urinary tract obstruction

A
  1. kidney stones
  2. local cancer masses pressing on ureters
  3. ureter strictures
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5
Q

4 causes of lower urinary tract obstruction

A
  1. BPH
  2. prostate cancer
  3. urethra strictures
  4. neurogenic bladder
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6
Q

definition of neurogenic bladder

A

no neurological signal to the bladder telling it to contract

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7
Q

5 complications of obstructive uropathy

A
  1. AKI (post-renal)
  2. CKD
  3. infection due to pooling of urine and retrograde infection
  4. dilated kidney, ureters or bladder
  5. pain
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8
Q

what is the most common type of kidney tumour

A

renal cell carcinoma

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9
Q

typical metastasis of renal cell carcinoma

A

cannon ball metastases in the lungs

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10
Q

presentation of renal cell carcinoma

A
  • often asymptomatic
  • haematuria
  • vague loin pain
  • non-specific cancer symptoms: weight loss, fatigue, anorexia, night sweats, lethargy
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11
Q

2 most common types of renal cell carcinoma and prevalence + common renal tumour in children

A
  1. clear cell (75-90%)
  2. papillary (10%)
    Wilms tumor in children <5yo
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12
Q

5 risk factors for renal cell carcinoma

A
  1. smoking
  2. obesity
  3. hypertension
  4. long-term dialysis
  5. Von Hippel-Lindau disease
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13
Q

management approach for renal cell carcinoma

A

first-line = surgery (partial nephrectomy)

+/- radiotherapy and chemotherapy

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14
Q

3 paraneoplastic features of renal cell carcinoma and pathophysiology

A
  1. polycythaemia - RCC secretes unregulated erythropoietin
  2. hypercalcaemia - RCC secretes hormone which mimics PTH
  3. Stauffer syndrome - abnormal LFTs demonstrating obstructive jaundice but no localised liver or biliary metastasis
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15
Q

5 types of bladder cancer and prevalence

A
  1. transitional cell carcinoma (90%)
  2. squamous cell carcinoma (10%)
    RARE:
  3. adenocarcinoma
  4. sarcoma
  5. small cell carcinoma
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16
Q

investigations for diagnosis of bladder cancer

A

cystoscopy and biopsy

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17
Q

typical presentation of bladder cancer

A

painless haematuria

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18
Q

risk factors/associations for bladder cancer

A
  • smoking

- carcinogens found in hair dyes, industrial paint, rubber, motor, leather

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19
Q

risk factor for squamous cell bladder cancer

A

schistosomiasis (in countries with high prevalence)

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20
Q

treatment for bladder cancer which is not invading the muscle

A

transurethral resection of a bladder tumour = TURBT
chemo after surgery
BCG vaccine injection into bladder via catheter:
- weekly treatments for 6 weeks
- then every six months for 3 years

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21
Q

treatment for bladder cancer which has invaded the muscle

A
  • radical cystectomy with ileal conduit
  • radiotherapy
  • IV chemotherapy
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22
Q

pathophysiology of benign prostatic hyperplasia

A

hyperplasia (more cells not bigger cells) of the stromal and epithelial cells of the prostate

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23
Q

presentation of BPH

A

lower urinary tract symptoms (LUTS)

  • hesitancy
  • frequency
  • urgency
  • intermittency
  • straining to void
  • terminal dribbling
  • incomplete emptying
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24
Q

investigations/assessments for BPH

A
  1. urine dipstick - exclude infection
  2. PSA - done PRIOR to rectal exam (falsely elevates result) to exclude cancer
  3. rectal exam - assess size, shape and characteristics
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25
Q

management of BPH (mild symptoms)

A

reassurance and monitoring

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26
Q

2 medical management options for BPH

A
  • alpha-blockers to relax smooth muscle e.g. Tamsulosin 400mcg OD
  • 5-alpha reductase inhibitors to block testosterone and reduce prostate size e.g. finasteride
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27
Q

4 options for surgical management of BPH

A
  1. transurethral resection of the prostate (TURP)
  2. transurethral electrovaporisation of the prostate (TUVP)
  3. holmium laser enucleation of the prostate (HoLEP)
  4. open prostatectomy via abdo or perineal incision
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28
Q

what is a TURP procedure

A

transurethral resection of the prostate (TURP)
accessing the prostate through the urethra and ‘shaving’ prostate tissue using diathermy to create a wider space for urine to flow

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29
Q

complications of a TURP procedure and mnemonic

A

FIRES

  • failure to resolve symptoms
  • incontinence
  • retrograde ejaculation
  • erectile dysfunction
  • strictures
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30
Q

risk factors for prostate cancer

A
  • increasing age
  • FHx
  • Black
  • tall
  • use of anabolic steroids
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31
Q

presentation of prostate cancer

A 
lower urinary tract symptoms (LUTS)
- hesitancy
- frequency
- urgency
- intermittency
- straining to void
- terminal dribbling
- incomplete emptying
also haematuria, erectile dysfunction, signs of cancer (FLAWS)
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32
Q

use of PSA in prostate cancer

A

not very sensitive or specific (false positives and false negatives)
useful in monitoring progression of disease and success of treatment

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33
Q

feeling of prostate on PR: benign vs cancerous

A
  • benign: smooth, symmetrical, slightly soft, maintained central sulcus
  • cancerous: firm/hard, asymmetrical, craggy, irregular, loss of central sulcus
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34
Q

investigations for suspected prostate cancer

A
  • PR, PSA

- prostate biopsy (multiple needle biopsies required)

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35
Q

2 types of prostate biopsy

A
  1. transrectal ultrasound-guided biopsy (TRUS):
    - US inserted into rectum and needle biopsy taken through rectal wall
    - ~10 biopsies taken
  2. transperineal biopsy:
    - more biopsies taken (~35)
    - higher sensitivity than TRUS but takes longer and requires GA
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36
Q

what grading system is used in prostate cancer and overview

A

Gleason - helps determine what tx is most appropriate
relating to histological appearance, higher grade = worse prognosis
from grade 1 = well differentiated to grade 5 = anaplastic (poorly differentiated)

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37
Q

5 types of tx for prostate cancer

A
  1. watchful waiting
  2. radiotherapy
  3. brachytherapy
  4. hormonal tx (antiandrogen)
  5. surgical
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38
Q

what is brachytherapy

A
  • radioactive seeds implanted into prostate

- delivers continuous, targeted radiotherapy to prostate

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39
Q

mechanism of hormone therapy in prostate cancer

A

block androgens (e.g. testosterone) to slow/stop growth of cancer

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40
Q

options for hormone therapy in prostate cancer

A
  • bilateral orchidectomy
  • LHRH agonists (e.g. goserelin) cause chemical castration
  • androgen receptor blockers (e.g. bicalutamide)
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41
Q

surgical tx of prostate cancer

A

prostatectomy

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42
Q

side effects of hormone therapy for prostate cancer

A
  • hot flushes
  • sexual dysfunction
  • gynaecomastia
  • fatigue
  • osteoporosis
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43
Q

4 complications of prostatectomy/radiotherapy tx

A
  1. erectile dysfunction
  2. urinary incontinence
  3. radiation-induced enteropathy (GI symptoms such as PR bleeding, pain, incontinence)
  4. urethral strictures
44
Q

definition of epididymo-orchitis

A

inflammation/infection of the epididymis and teste

45
Q

4 causes of epididymo-orchitis

A
  1. e. coli
  2. chlamydia trachomatis
  3. neisseria gonorrhoea
  4. mumps
46
Q

presentation of epididymo-orchitis

A
  • (usually) unilateral testicular pain and tenderness of gradual onset (mins) with dragging/heavy sensation
  • urethral discharge (chlamydia/gonorrhoea)
  • tender on palpation
  • swelling and erythema
47
Q

management of epididymo-orchitis

A
  • admit and treat sepsis if indicated, otherwise as OP
  • abx e.g. ciprofloxacin for 2/52
  • tight underwear for scrotal support
  • abstain from intercourse
48
Q

investigation for epididymo-orchitis

A

confirm with US - exclude torsion and tumour

49
Q

typical presentation of testicular torsion

A
  • teenage boy
  • acute/sudden onset unilateral testicular pain
  • triggered by playing sport/activity
50
Q

complication of testicular torsion

A

subfertility/infertility

51
Q

what is the window for testicular torsion and how long is it

A

time after onset before the damage from ischaemia is irreversible
6 hours

52
Q

examination findings in testicular torsion

A
  • acutely tender testicle
  • may be too tender to examine
  • firm testicle
  • absent cremasteric reflex
  • abnormal lie: horizontal, rotated, elevated/retracted
53
Q

what anatomical variant is associated with testicular torsion

A

bell-clapper deformity

  • testicle normally fixed posteriorly to tunica vaginalis
  • in bell-clapper deformity this fixation is absent
  • allows testicle to rotate within tunica vaginalis which can twist vessels and cut off blood supply
54
Q

management of testicular torsion

A 
urgent urology assessment
immediate surgical intervention 
- untwist
- fix both testicles into correct position (orchiopexy)
- possible orchidectomy if necrotic
55
Q

7 differentials for testicular lump

A
  1. testicular cancer
  2. hydrocoele
  3. varicocoele
  4. epidydimal cyst
  5. epididymo-orchitis
  6. inguinal hernia
  7. testicular torsion
56
Q

definition of hydrocoele

A

fluid build-up within the tunica vaginalis membrane

57
Q

examination findings in hydrocoele

A
  • transilluminated by shining torch into fluid
  • soft, fluctuant, may be large
  • irreducible, no bowel sounds
58
Q

definition of varicocoele

A

swollen pampiniform venous plexus (testicular veins)

59
Q

examination findings in varicocoele

A
  • soft, ‘bag of worms’

- may cause dragging or soreness

60
Q

definition of epididymal cyst

A

sac of fluid at the epididymis

61
Q

examination findings in epididymal cyst

A
  • soft, fluctuant lump at the top of the testicle
62
Q

examination findings in inguinal hernia

A
  • separate from testicle
  • soft
  • bowel sounds
  • reducible
63
Q

anatomy of the testicular veins

A
  • R testicular vein arises from IVC

- L testicular vein arises from L renal vein

64
Q

what to consider in unilateral varicocoele

A

if unilateral left sided varicocoele, can indicate obstruction of L testicular vein (from L renal vein) e.g. caused by renal cell carcinoma

65
Q

2 main types of testicular cancer

A

germ cell cancer:

  • seminoma
  • teratoma
66
Q

tumor markers in testicular cancer

A
  • alpha-fetoprotein (raised in teratomas)
  • beta-hCG (raised in teratomas > seminomas_
  • lactate dehydrogenase
67
Q

4 sites of metastasis for testicular cancer

A
  1. lymphatics
  2. lungs
  3. liver
  4. brain
68
Q

prognosis for testicular cancer

A

good prognosis unless metastatic

seminomas have slightly better prognosis

69
Q

treatment for testicular cancer

A
  • orchidectomy (+ testicular prosthesis)
  • chemo / radiotherapy depending on staging
  • monitor post-tx with tumour markers and imaging
70
Q

definition of pyelonephritis

A

infection in the renal pelvis (join between kidney and ureter) and parenchyma

71
Q

risk factors for pyelonephritis

A
  • female
  • structural urological abnormalities
  • diabetes
72
Q

4 most common causative organisms for pyelonephritis

A
  1. E. coli
  2. klebsiella
  3. enterococcus
  4. pseudomonas
73
Q

presentation of pyelonephritis

A
  • high fever and rigors
  • loin to groin pain
  • dysuria, urinary frequency
  • haematuria
  • non-specific symptoms e.g. vomiting
  • pain on bimanual palpation of the renal angle
74
Q

urine dipstick results in pyelonephritis

A
  • blood
  • protein
  • leucocyte esterase (produced by neutrophils)
  • nitrites (gram-neg organisms metabolise nitrates -> nitrites)
75
Q

investigations in pyelonephritis

A
  • CT to confirm dx
  • USS in children
  • DMSA scans to indicate level of scarring in recurrent pyelonephritis
76
Q

management of pyelonephritis

A
  • blood and urine culture
  • broad-spectrum abx (co-amoxiclav) until culture + sensitivities back
  • admit if systemically unwell
  • IV rehydration
  • analgesia
  • antipyretics
77
Q

complications of chronic pyelonephritis

A
  • scarring of renal parenchyma
  • CKD
  • abscess/pus in or around kidney
78
Q

4 types of renal stones

A
  1. calcium oxalate (80%)
  2. calcium phosphate
  3. uric acid
  4. struvite (magnesium ammonium phosphate) - can be staghorn
79
Q

what is a staghorn calculus

A

renal calculus which forms the shape of a staghorn - body sits in renal pelvis with horns extending into renal calyxes
usually struvite

80
Q

how is a staghorn calculus formed

A

recurrent upper UTI -> bacteria hydrolyse urea in urine to ammonia, creating solid struvite

81
Q

presentation of renal stones

A
  • may be asymptomatic
  • renal colic
  • excruciating loin to groin pain
  • colicky as stones move and settle
  • haematuria, nausea, vomiting, oliguria
  • may be septic
82
Q

investigations to diagnose renal stones

A
  • urine dipstick (haematuria +/- exclude infection)
  • bloods: FBC, CRP, U&E
  • AXR but may not be visible
  • CT KUB gold standard (non-contrast CT)
83
Q

management of renal stones

A
  • NSAIDs e.g. PR diclofenac
  • antiemetic if needed
  • fluids
  • abx if infection
  • smaller stones (<6mm) may pass spontaneously
  • tamsulosin (alpha-blocker) to aid passage
  • surgical intervention if needed
84
Q

4 surgical intervention options for renal stones

A
  1. extracorporeal shock wave lithotripsy (x-ray guided breaking up of stones by shock waves)
  2. ureteroscopy and laser lithotripsy (stone broken up by lasers, guided via camera through urethra/bladder/ureter)
  3. percutaneous nephrolithotomy (small incision in back, stones removed or broken up)
  4. open surgery
85
Q

advice to prevent recurrent renal stones

A
  • increase oral fluids
  • reduce dietary salt intake
  • reduce intake of oxalate-rich foods e.g. spinach, nuts, rhubarb, tea
  • reduce intake of urate-rich foods e.g. kidney, liver, sardines
  • limit dietary protein
86
Q

prophylaxis for calcium renal stones

A

thiazide

87
Q

risk factors for erectile dysfunction

A
  • increasing age
  • CVD risk factors: obesity, DM, dyslipidaemia, metabolic syndrome, HTN, smoking
  • alcohol
  • drugs: SSRIs, beta-blockers
88
Q

investigations for erectile dysfunction

A
  • calculate QRISK score for CVD (measure lipid and fasting glucose)
  • free testosterone measured between 9-11am
  • repeat testosterone with FSH/LH/prolactin levels if low or borderline
89
Q

most important risk factor for testicular cancer

A

infertility -> 3x more likely to develop testicular ca if infertile

90
Q

histological appearance of clear cell carcinoma

A

variegated, septated interior (different colours and separate compartments e.g. solid and liquid)

91
Q

triad for renal cancer sx

A

flank pain
mass
haematuria

92
Q

how does gynaecomastia occur in testicular cancer

A

increased oestrogen:androgen ratio

93
Q

what is a nephroblastoma

A

wilm’s tumour
renal cancer usually presents in first 4 years of life
presents as a mass associated with haematuria (+/- pyrexia)

94
Q

tumour markers in testicular cancer patterns

A

AFP (alpha-fetoprotein) and HCG +/- lactate dehydrogenase (LDH)
raised in teratomas and yolk sac tumours, normal in seminomas

95
Q

causes of hydronephrosis: unilateral vs bilateral

A 
unilateral:
- pelvic-ureteric obstruction
- renal vessel abnormality
- calculi
- tumours of renal pelvis
bilateral:
- urethral stenosis
- urethral valve
- prostatic enlargement
- extensive bladder tumor
- retro-peritoneal fibrosis
96
Q

investigations for hydronephrosis

A

USS
IV urogram
antegrade/retrograde pyelography
CT (non-contrast) if renal colic suspected

97
Q

management of hydronephrosis

A

remove obstruction and drain urine

  • nephrostomy if acute upper urinary tract obstruction
  • ureteric stent or pyeloplasty if chronic obstruction
98
Q

causative organisms of epididymo-orchitis and epidemiology

A

sexually active <35yo = chlamydia trachomatis

>35yo = e. coli

99
Q

criteria for doing a PSA test

A

at least:

  • 6 weeks after prostate biopsy
  • 4 weeks after UTI
  • 1 week after PR
  • 48 hours after vigorous exercise
  • 48 hours after ejaculation
100
Q

main findings on examination of epidydimal cyst

A

can palpate above the swelling
non-tender
above and behind testis

101
Q

main findings on examination of hydrocoele

A

transilluminates

soft, fluctuant

102
Q

3 main things to assess with a scrotal swelling

A
  1. involving testicle or not
  2. trans-illumination
  3. able to palpate above the swelling
103
Q

main findings on examination of inguinal hernia

A

cannot get above it

may be reducible

104
Q

main findings on examination of epididymo-orchitis

A

tender, eased by elevating testis

hx of dysuria and discharge

105
Q

main findings on examination of varicocoele

A

LHS > RHS (testicular vein drains into renal vein)

106
Q

treatment of prostatitis

A

14 day course of quinolone (ciprofloxacin)

Renal and Uro (2 decks)

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