Uro/renal

Question 1

Benign Prostate Hyperplasia

Answer 1

Enlargement of the prostate.
C: Unknown. Function of 5a reductase increases with age which converts testosterone to DHT. DHT prevents apoptosis allowing continued cell growth.
Risk Factors = age, family history, Afro-Caribbean, obesity.
S: Either storage, voiding or mixture of symptoms.
Storage = frequency, nocturia, urgency, urgency with incontinence.
Voiding = hesitation, poor flow, incomplete emptying, terminal dribbling, straining.
Haematuria and dysuria are red flags. May have urinary retention.
D: Urinanlysis, DRE, urine flow study, Post void bladder scan, PSA, Transrectal ultrasound.
T: Advice - moderate caffeine and alcohol, train bladder. 1st line: alpha-blockers (e.g. Tamsulosin). 2nd line: 5a–reductase inhibitor (e.g. Finasteride).
Surgery includes TURP – transurethral resection of prostate, TUVP – transurethral electrovaporisation of prostate or open prostatectomy via abdominal or perineal incision.

Question 2

Stress incontinence

Answer 2

Involuntary leakage on effort or exertion, or on sneezing or coughing.
C: Pelvic floor muscles and urethral sphincter becomes weak. Usually due to childbirth in women and damage to the bladder or surrounding area during surgery in men. Also due to neuro conditions like Parkinsons.
S: Involuntary urine leakage, vaginal bulge/pressure, urogenital atrophy.
D: Empty supine stress test - urine leakage, urinalysis, cough stress test - urine leakage, bladder diary.
T: Behavioural therapy. 1st line is alpha-agonist (pseudoephedrine) with adjunctive oestrogen if post-menopausal.

Question 3

Urge incontinence

Answer 3

Involuntary leakage accompanied by, or immediately preceded by, a sudden compelling desire to pass urine which is difficult to defer (urgency).
C: Overactivity of detrusor muscles, comorbidities (type 2 diabetes, obesity, chronic UTIs), certain drugs (parasympathomimetics, antidepressants + hormone replacement therapy).
S: Involuntary urine leakage accompanied by or immediately preceded by urgency. Nocturia.
D: Empty supine stress test - urine leakage, Urinalysis, bladder diary.
T: 1st line = behavioural approaches and lifestyle changes (bladder retraining, pelvic muscle exercises, weight loss, caffeine reduction etc).
2nd line = pharmacotherapy - oxybutynin.

Question 4

Prostate Cancer

Answer 4

Slow-growing tumour of the prostate gland.
C: Neoplasia of epithelial cells – mutation occurs in prostate cells which then avoid apoptosis and divide in uncontrolled way. Risk factors: increasing age, family history, Afro-Caribbean, Genetics, Diet (red meat).
S: Lower urinary tract symptoms (LUTS) including storage symptoms – frequency, nocturia, urgency +/- incontinence and voiding symptoms – hesitation, poor flow, incomplete emptying, terminal dribbling. Haematuria or erectile dysfunction, weight loss, sweating at night, fatigue, bone pain, anaemia.
D: DRE (firm/hard, asymmetrical, craggy or irregular), neuro exam, bladder palpation, bony tenderness, PSA, prostate MRI, Transrectal or Transperineal prostate biopsy.
T: Treatment depends on staging, grade, age, co-morbidities, life expectancy. Watchful waiting if low-risk. Radiotherapy – localized or locally advanced cancer.
Hormonal treatment (anti-androgen therapy). Surgery – total prostatectomy – used in localized prostate cancer <70.

Question 5

Bladder cancer

Answer 5

A growth of abnormal tissue, known as atumour, develops in thebladderlining, may spread into the bladder muscle.
C: Smoking, second-hand smoke, occupational exposure to chemical carcinogens, such as aromatic amines and polycyclic aromatic hydrocarbons, exposure to drugs (e.g. phenacetin, cyclophosphamide), chronic inflammation.
S: Painless haematuria (either visible or non-visible), sometimes symptoms suggestive of a UTI (frequency, urgency, dysuria).
D: Urinalysis, cystoscopy, CT/MRI.
T: Transurethral resection of a bladder tumour (TURBT) and localised chemo for low-risk. At least 6 doses of chemotherapy using a catheter for intermediate risk. A second TURBT, a course of Bacillus Calmette-Guérin (BCG) treatment, and a cystectomy for high-risk. If muscle invasive, cystectomy or radiotherapy with adjunctive chemo.

Question 6

Testicular cancer

Answer 6

Cancer develops in the testicular cells. Can be unilateral or bilateral. Good 5 year survival rate.
Germ cell tumours: Seminomas, Non-seminomas germ cell tumours, Embryonal carcinoma, Choriocarcinoma, Teratoma.
Gonadal stromal tumours: Sertoli cell, Leydig cell, Granulosa cell.
C: Unknown. Chromosome 12q mutations are usually present.
S: Painless/painful testis mass, lower abdo pain, increased size of testis, gynecomastia, metastasis evidence: dyspnoea, haemoptysis, palpable lymph nodes, bone pain
D: CXR, CT/MRI scan, ultrasound, elevated AFP and B-hCG in NSGCT, elevated lactase dehydrogenase in GCT.
T: Surveillance - Regular AFP/β-hCG serum-level monitoring, Chemotherapy, stem cell transplantation, surgery.

Question 7

Acute glomerulonephritis

Answer 7

A specific set of renal diseases in which an immunologic mechanism triggers inflammation and proliferation of glomerular tissue that can result in damage.
C: Usually post-infection with group A β-haemolytic streptococcus. Can also be caused by Staphylococcus, mumps, Legionella, hepatitis B and C, schistosomiasis, malaria. Can be associated with infective endocarditis, visceral abscess, SLE, shunt nephritis.
S: Haematuria (visible or non-visible), proteinuria, hypertension and oedema, Oliguria, Uraemia (high urea).
D: Urinalysis, FBC, U&Es, immunology (anti-GBM, ANCA, ANA, complement levels), biopsy, ultrasound, CXR, CT scan, intravenous pyelogram.
T: Spontaneous recovery should take place. Hypertension is treated with salt restriction, loop diuretics and vasodilators.
Fluid balance is monitored by daily weighing and daily recording of fluid input and output.

Question 8

IgA nephropathy

Answer 8

Abnormal IgA forms and deposits in the kidneys, causing kidney damage.
C: Abnormal glycosylation of the serine and threonine residues, causing IgAs to be galactose deficient. They are not recognised and not degraded, allowing them to accumulate, and IgG are produced against them. Typically develops during an infection in the mucosal lining, like infections of the gastrointestinal or respiratory tract.
S: Microscopic or gross haematuria, urine shows erythrocytes, casts and proteinuria, AKI or CKD, loin pain.
D: Urinalysis, urine microscopy, 24 hours of protein excretion, U&Es, creatinine and a 24-hour creatinine clearance test, plama IgA (poor test).
T: No cure but prevent further damage. Control blood pressure - good diet, low salt and cholesterol, antihypertensives.
Corticosteroids like prednisone, prevents the production of IgA1 and anti-glycan IgG

Question 9

Nephrotic syndrome

Answer 9

Increased filtration of macromolecules across the glomerular capillary wall due to structural and functional damage of the basement membrane.
C: Primary - Minimal change glomerular disease, Focal segmental glomerulosclerosis and membranous glomerulonephritis,
Secondary - infection, SLE, RA, polyarteritis nodosa, DM, hereditary nephritis, sickle cell disease, malignancy, medications, toxins, pregnancy, transplant rejection.
S: Peripheral oedema usually ankles and legs but can progress, frothiness of their urine, arterial or venous thromobosis, recurrent infections and/or general fatigue, lethargy, poor appetite, weakness, breathlessness, dyslipidaemia: eruptive xanthomata, xanthelasmata.
D: Urinalysis, MSU, urinary protein:creatinine ratio, FBC, coag, U&Es, ESR, CRP, autoimmune screen, fasting glucose, CXR and abdominal or renal ultrasound scan, biopsy.
T: Sodium and fluid restriction and high-dose diuretic treatment - furosemide (~1 mg/kg/day) ± spironolactone (~2 mg/kg/day). Check weight regularly. Corticosteroids in children. ACEi may be used in adults.

Question 10

Minimal change disease

Answer 10

Most common nephrotic disease in children. The glomeruli are damaged and become more permeable, allowing plasma proteins into the nephron and the urine, causing proteinuria. The damage can only be seen under an electron microscope.
C: In adults it’s usually secondary. In children it’s usually idiopathic or caused by allergic reactions, NSAIDs, tumours, viral infections.
S: Foamy urine, oedema, weight gain, nephrotic syndrome (proteinuria, oedema, hypoalbuminemia, dyslipidemia).
D: Urinalysis, FBC, eGFR, kidney biopsy.
T:Salt and fluid restriction, diuretics, ACEi/ARB, corticosteroids (prednislone). If steroid-resistent, levamisole, alkylating agents, calcineurin inhibitors, antiproliferatives, and rituximab.

Question 11

Erectile dysfunction

Answer 11

Unable to develop or maintain an erection during sex.
C: Psychological - stress, performance anxiety, depression, physiological - atherosclerosis, blood vessel damage due to HTN or DM, stroke, multiple sclerosis, back or pelvis trauma can directly damage the nerves, hypogonadism, Peyronie’s disease, medication side-effects (diuretics, antidepressants, methadone).
S: Difficulty developing or maintaining an erection, decreased libido, may have premature or delayed ejaculation, anorgasmia.
D: HbA1c, morning sample of total testosterone, FSH, LH, rigidity studies, vascular studies (duplex ultrasound), neurological studies, endocrine work-up,psychodiagnostic evaluation.
T: PDE-5 inhibitors (sildenafil) - inhibit the PDE-5 enzyme in endothelial cells (normally breaks down cGMP), leading to higher levels of cGMP, leading to more smooth muscle relaxation
Vacuum erection device - applying negative pressure around the penis, which can help draw in blood
Prosthetic implants - can keep the penis rigid.

Question 12

Priapism

Answer 12

Involuntary, persistent erection unrelated to sexual stimulation and unresolved by ejaculation.
C: Often idiopathic, Low flow - Hypercoagulable state (sickle cell anaemia, anaemia, thalassemia), Neurological disease (spinal cord stenosis), Metastatic disease (prostate cancer, bladder cancer), Medication relaxing smooth muscles (prostaglandins, hydralazine), High flow - Penile/perineum trauma (artery rupture, fistula).
S: Persistent erection lasting 30 minutes to 3 hours. Low flow - painful, corporeal aspiration (dark blood).
D: Doppler ultrasound, CT scan, Penile blood gas measurement, FBC, Selective angiography.
T: Low flow - intracavernosal injection of sympathomimetic agent e.g. phenylephrine (pure alpha agonist effects)
Treat underlying condition
Corporal aspiration with/without saline irrigation
High flow - identification, obliteration of fistulas with selective arterial embolisation

Question 13

Chronic kidney disease

Answer 13

Subtle decline in function that develops over a minimum of 3 months.
C: Hypertension, DM, SLE, RA, HIV, NSAIDs and other medications, toxins like tobacco.
S: Ureamia, loss of appetite and nausea, encephalopathy which leads to asterixis, pericarditis, bleeding, Uremic frost (uric crystals in skin), hyperkalaemia and cardiac arrythmias, hypocalcaemia and renal osteodystrophy, hypertension.
D: Changes in GFR over time - may be suspected if GFR is less than 90ml/min/1.73m2
Irreversible kidney damage is diagnosed if the GFR is less than 60ml/min/1.73m2
Biopsy - look for glomerulosclerosis
T: Managing the underlying cause. Dialysis. Kidney transplant.

Question 14

Urinary tract infections

Answer 14

Bacteria typically enter the bladder through the urethra.
C: Commonly E.coli, can also be caused by Proteus, Klebsiella, Enterococci, Staph.saprophyticus, S.aureus, Pseudomonas aeruginosa.
More common in women, the elderly, hospitalised patients, patients using a catheter, new sexual activity.
S: Lower UTI: frequency of micturition, dysuria, suprapubic pain and tenderness, haematuria and smelly urine.
Upper UTI (acute pyelonephritis): loin pain and tenderness, nausea, vomiting, fever.
Can be asymptomatic. New confusion in the elderly.
D: Uncomplicated UTIs in younger women with 2 of the 3 (dysuria, urgency or frequency) can be treated without diagnostic tests.
Otherwise, urinalysis and MSU culture.
T: Antibiotics for uncomplicated (3 days) and complicated (7 days).
Lower: Trimethoprim–sulfamethoxazole or nitrofurantoin.
Upper: Antibiotics are given intravenously, e.g. aztreonam, cefuroxime, ciprofloxacin or gentamicin, switching to a further 7 days oral treatment as symptoms improve.
Fluid intake and hygiene advice.

Question 15

Acute pyelonephritis

Answer 15

Inflamed kidney that develops relatively quickly, usually a result of a bacterial infection. Type of upper UTI.
C: Most commonly caused by ascending infection from the lower urinary tract. E.coli, Proteus and Enterobacter. Commonly found in the bowel flora.
Haematogenous infection can also occur from septicaemia or infective endocarditis.
S: Leucocytosis, fevers, chills, nausea and vomiting, flank pain at the costovertebral angle, systemic symptoms help distinguish from a lower UTI.
D: Urinalysis, MSU culture, CRP, ESR, FBC, blood cultures, Ultrasonography, Contrast-enhanced helical/spiral CT, renal biopsy, MRI scan.
T: Fluid intake, analgesia, first-line antibiotic should be either ciprofloxacin or co-amoxiclav for seven days, Trimethoprim may be used if culture confirms sensitivity. Surgery may be used to drain renal or perinephric abscesses.

Question 16

Chronic pyelonephritis

Answer 16

Recurrent episodes of acute pyelonephritis can lead to permanent scarring of the kidney. Type of upper UTI.
C: Predisposition to recurrence i.e. vesicoureteral reflux caused by bladder outlet obstruction or a primary congenital defect. Chronic obstruction caused by congenital malformations or BPH, or cervical carcinoma in women, kidney stones.
S: Dysuria, pain in back, abdomen or loin, nocturia, repeated UTIs, signs of infection (fever, unintentional weight loss, malaise, decreased appetite), haematuria.
D: Kidney ultrasound or intravenous pyelogram, nuclear medicine scan, MRI scan, micturating cystourethrogram.
T: Correcting the underlying cause by removing obstructions or surgery to correct congenital cause
Dialysis
Nephrectomy

Question 17

Urinary colic

Answer 17

Intense pain caused by obstruction in the ureter where a stone stretches the ureter walls.
C: Characterized by the presence of a urinary stone (from the kidney or bladder) becoming lodged in the narrowest areas of the ureter such as the pelvi-ureteric junction, near the pelvic brim at the crossing of the iliac vessels, vesico-ureteric junction.
S: Waves of severe pain usually lasting 20-60 minutes, severe sharp colicky pain from ‘loin to groin’, dysuria, frequency and urgency to pass urine, vomiting, nausea, dehydration, haematuria.
D: Non-contrast CT scan to identify stones, urinalysis, blood tests to look for elevated calcium, uric acid and oxalate levels.
T: For stones that pass freely: NSAIDs or opiates to relieve pain, calcium antagonists to suppress ureteral contraction, IV fluids, antiemetics.
For stones too large to pass:stent placement, extracorporeal shockwave lithotripsy, percutaneous nephrolithotomy.

Question 18

Kidney stones

Answer 18

AKA nephrolithiasis, urolithiasis or renal calculi.
Form when solutes in the urine precipitate out and crystalize.
C: Occur if there is an increase in the solute or a decrease in the solution (dehydration). Most commonly the inorganic precipitate is calcium oxalate (dark brown). Calcium phosphate can also cause renal stones (dirty white). Urate acid stones (Red/brown). Struvite stones (Mix of magnesium, ammonium and phosphate) (dirty white). Cystine stones (yellow/light pink). Xanthine stones (red/brown).
S: Dull or localised flank pain on the mid to lower back
Renal colic - sharp and constant
D: History, physical exam, imaging - X-ray, CT scan, ultrasound, urinalysis - might show microscopic or gross haematuria.
T: Hydration, medications - reduce pain (analgesia), reduce stone formation (potassium citrate), help stones pass (alpha adrenergic blockers and calcium channel blockers)
Shockwave lithotripsy - using high-intensity acoustic pulses to break up the kidney stones
Surgery
Stents

Question 19

Balanitis

Answer 19

Inflammation of the glans penis. If the foreskin is also inflamed, the correct term is balanoposthitis, although balanitis is commonly used to refer to both.
C: Irritation or contact dermatitis, trauma, stevens-Johnson syndrome, severe oedema due to RHF, morbid obesity, polymicrobial bacterial infection or viral infection.
S: Non-retractile foreskin, penile ulcerations, plaques, satellite lesions, may be purulent and/or foul-smelling discharge, interference with urinary flow, impotence or pain during coitus, regional lymphadenopathy.
D: Swab of discharge for microscopy, Gram staining, culture and sensitivity, STI testing, blood/urine testing for DM.
T: Daily cleaning with warm water, followed by gentle drying. Treat underlying cause. If a nonspecific dermatitis or contact dermatitis is suspected avoid triggers, and apply hydrocortisone 1% once daily for 14 days.
If candida infection , apply clotrimazole cream 1% or miconazole cream 2%.
If bacterial infection is suspected, take a swab and wait for the results. Usually flucloxacillin or erythromycin..
If anaerobic infection is suspected, metronidazole 400 mg twice-daily for one week.

Question 20

Prostatitis

Answer 20

Prostatitis is inflammation of the prostate gland.
C: Bacterial (E coli, Enterobacter, Serratia, Pseudomonas and Proteus species, STIs, Mycobacterium tuberculosis), Non-bacterial (elevated prostatic pressures, pelvic floor myalgia, emotional disorders).
S: Fever, malaise, arthralgia and myalgia, Urinary frequency, urgency, dysuria, nocturia, hesitancy and incomplete voiding, low back pain, low abdominal pain, perineal pain and pain in the urethra, pain on ejaculation, urethral discharge.
D: FBC, U&E and creatinine, blood cultures, urine culture, PSA (high).
T: Acute - analgesia, suprapubic catheter, Flouroquinolones are first-line (eg, ciprofloxacin or ofloxacin), second-line are trimethoprim-sulfamethoxazole and macrolides. Chronic - analgesia and stool softeners, same antibiotics, transurethral resection of the prostate (TURP) or total prostatectomy may be required.

Question 21

Epididymitis

Answer 21

The epididymis, a long, coiled tube at the back of each of a man’s two testicles, is inflamed.
C: Commonly gonorrhoea and chlamydia. Also - E.coli and tuberculosis.
Risk factors - history of STIs, UTIs, prostatitis, BPH, uncircumcision.
S: Swelling, pain, usually unilateral, redness, or tenderness in the scrotum, frequency, dysuria, fever, haematuria, lower abdo pain, enlarged lymph nodes.
D: Scrotal examination, rectal and prostate examination, urinalysis, blood tests, swabs, ultrasound.
T: If high risk N. gonorrhoeae or any other sexually transmitted pathogen: Ceftriaxone 1 g IM in 1% lidocaine plus doxycycline for 10-14 days. If most probably Chlamydia/other non-gonococcal pathogen: Doxycycline 100 mg for 10-14 days or ofloxacin 200 mg for 14 days.

Question 22

Orchitis

Answer 22

Orchitis is an inflammation of the testicles. May be unilateral or bilateral.
C: Viral (mumps), Bacterial (UTIs or STIs such as gonorrhoea or chlamydial, epididymitis where inflammation spreads from the epididymis to the testes too)
S: Pain in testicles and groin, tenderness in scrotum, dysuria, painful ejaculation, swollen scrotum, blood in the semen, abnormal discharge, fever, enlarged prostate, lymph nodes.
D: Prostate examination, urine swab and discharge swab, ultrasound to rule out torsion.
T: Viral orchitis - Analgesia, applying ice and elevating the testicles.
Bacterial orchitis - antibiotics, anti-inflammatory medications, and cold packs.
Abstinence from sexual intercourse.
if high risk N. gonorrhoeae or any other sexually transmitted pathogen: Ceftriaxone 1 g IM in 1% lidocaine plus doxycycline for 10-14 days. If most probably Chlamydia/other non-gonococcal pathogen: Doxycycline 100 mg for 10-14 days or ofloxacin 200 mg for 14 days.

Question 23

Urethritis

Answer 23

The urethra, or the tube that carries urine from the bladder to outside the body, becomes inflamed and irritated.
C: Viral (HPV, HSV, CMV), bacterial (Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium), genital trauma (e.g. from a catheter).
S: Men (burning, itching, blood in semen or urine, penile discharge), women (urgency, dysuria, burning, irritation, abnormal vaginal discharge).
D: Examination of the genital area for discharge, tenderness, sores and any signs of an STI, urine sample, swabs from the urethra or vaginal area, blood tests may be taken to check for other STIs, like HIV and syphilis.
T: Azithromycin, Doxycycline, Erythromycin, Ofloxacin or Levofloxacin depending on the sensitivity

Question 24

Haematuria

Answer 24

Types:
Visible haematuria (VH) also called macroscopic haematuria or gross haematuria.
Non-visible haematuria (NVH) also called microscopic haematuria or dipstick.
C: UTI, TB, protatitis, infective endocarditis, urethritis, renal/bladder/prostate/urethral/endometrial cancer, trauma, glomerulonephritis, IgA nephropathy, calculi, sickle cell disease, coagulation disorders, anticoagulation therapy, surgery, toxins.
S: Blood in the urine
D: Urinalysis, plasma creatinine, eGFR, protein:creatinine ratio, FBC, clotting screen.
T: Refer for 2WW:
Bladder or renal cancer: haematuria (visible and unexplained) either without UTI or that persists or recurs after successful treatment of UTI (patients aged 45 and over).
Bladder cancer: haematuria (non-visible and unexplained) with dysuria or raised white cell count on a blood test (patients aged 60 and over).
Endometrial cancer: haematuria (visible) with low haemoglobin levels or thrombocytosis or high blood glucose levels or unexplained vaginal discharge in women aged 55 years and over - consider a direct access ultrasound.
Prostate cancer: haematuria (visible) in men. Consider a prostate-specific antigen (PSA) test and digital rectal examination.

Question 25

Ureteric injury

Answer 25

Relatively uncommon.
Upper-third - Upper-third and pelvico-ureteric junction (PUJ) most affected by blunt trauma
Mid-third
Distal-third - most common site, often following iatrogenic injury
C: Iatrogenic - usually after gynaecological procedures. Trauma - direct trauma from penetrating injury is a more common cause than blunt injury.
S: Macro- or microscopic haematuria, abdominal/flank pain, renal failure and/or urine leaking from the vagina.
D: Excretory intravenous urography, CT scan, Retrograde pyelography if both are inconclusive.
T: Immediate diagnosis and appropriate corrective surgical procedure of the cause. Ureteric stents are often required.
If there is an obstruction and surgical treatment is not sufficient, percutaneous nephrostomy may be indicated.

Question 26

Acute urinary retention

Answer 26

The sudden inability to pass urine. It is usually painful and requires emergency treatment.
C: BPH, prostate cancer, balanitis, prostatitis and prostatic abscess, penile trauma, fracture or laceration, prolapse, pelvic mass, postpartum complications, stones, bladder cancer, faecal impaction, gastrointestinal or retroperitoneal malignancy, pelvic trauma, medications, neuropathy, normal pressure hydrocephalus, spina bifida, MS, cauda equina, Parkinson’s disease).
S: Unable to pass urine, tender and distended bladder with dullness to percussion, phimosis or meatal stenosis in men, vulval or vaginal inflammation or infection, prolapse, pelvic mass in women.
D: PR exam, neuro exam, urinalysis, MSU, FBC, U&Es, blood glucose, PSA, ultrasound, MRI/CT, cystoscopy, retrograde cystourethrography or urodynamic studies.
T: Catheter for immediate and complete bladder decompression. If BPH, alpha-blocker is prescribed before commencing TWOC.

Question 27

Chronic urinary retention

Answer 27

A bladder that does not empty completely or does not empty at all. May be able to urinate but experience LUTS.
C: BPH, Prostate cancer, drugs (Antispasmodics, Antihistamines, Anticholinergics, Botulinum toxin), colposuspension, congenital deformities, urethral strictures resulting from infection.
S: Urinary frequency, hestitancy, urgency, post-micturition dribbling, nocturia, incontinence, incomplete voiding, recurrent voiding, lower abdo pain, lethargy, pruritus, recurrent infections.
D: Urinalysis, MSU, FBC, U&Es, PSA, voiding diaries, urinary tract ultrasound, CT/MRI, urodynamic studies.
T: Fluids, reduce alcohol, bladder retraining and regular voiding, urethral catheterisation, surgery on the bladder outlet.

Question 28

Renal cell carcinoma

Answer 28

Most common of the tumours of the kidney in adults. RCC originates from the proximal renal tubular epithelium.
C: Hereditary or spontaneous - risk factors: smoking, obesity, hypertension, long-term renal dialysis, tuberous sclerosis, renal transplant recipients and acquired renal cystic disease.
S: Asymptomatic, triad of haematuria, loin pain and loin mass, fatigue, weight loss, macroscopic haematuria, palpable mass, ankle oedema, paraneoplastic symptoms.
D: Urinalysis, cytology, culture and sensitivity, FBC, U&Es, Intravenous urogram, CT scan, Cystoscopy, renal biopsy.
T: Surgery with or without radiotherapy and/or chemotherapy. Partial nephrectomy is considered first-line for tumour less than 7cm. Tumour nephrectomy and interferon alfa for metastatic disease. Radiotherapy for brain metastasis. Bisphosphonate therapy for bone metastasis.

Question 29

Wilm’s tumour

Answer 29

An undifferentiated mesodermal tumour of the intermediate cell mass (primitive renal tubules and mesenchymal cells). Most common intra-abdominal tumour in children.
C: Spontaneously, ‘Overgrowth syndromes’ (excessive prenatal and postnatal somatic growth), Edwards syndrome, hereditary.
S: Asymptomatic abdominal mass, abdominal pain, haematuria, UTI, hypertension, fever, respiratory symptoms due to lung metastases.
D: FBC, U&Es, urinalysis, ultrasound and/or intravenous pyelogram (IVP), Renal angiography, genetic studies, CT/MRI scan.
T: Nephrectomy followed by chemotherapy (regimes include vincristine, dactinomycin and doxorubicin),
routine postoperative radiotherapy to the flank.

Question 30

Cryptorchidism

Answer 30

Undescended and maldescended Testes. An undescended testis is a testis that is absent from the scrotum. Normally begins at mesodermal ridge, down to inguinal canal into scrotum.
C: Multifactorial (genetic, maternal and environmental factors). However, it occurs most often as an isolated disorder with no obvious cause.
Maldescended may be caused by an anatomical abnormality or due to hormone lack or hormone resistance.
S: The testicle cannot be seen or felt in the scrotum. Scrotum is smaller or flatter than normal.
D: Physical examination, Diagnostic laparoscopy, Abdominal and pelvic ultrasonography.
T: May descend spontaneously. At 3 months, referral to paediatric surgeon. Treatment with human chorionic gonadotrophin (hCG) or gonadotrophin-releasing hormone (GnRH) can be used.
Orchiopexy before 10-11 years may protect against the increased risk of testicular cancer.

Question 31

Hydrocele

Answer 31

A hydrocele is an abnormal collection of fluid within the remnants of the processus vaginalis.
C: Simple (congenital, trauma, epididymo-orchitis, testicular torsion, hernia, varicocele, and testicular tumour), Communicating (congenital, increased intra-abdominal pressure, fluid overload), Non-communicating (minor trauma, testicular torsion, epididymitis, repair of hydrocele).
S: Scrotal enlargement with a non-tender, smooth, cystic swelling, will transilluminate, not usually painful.
D: Ultrasound, Doppler ultrasound studies, Serum alpha-fetoprotein and human chorionic gonadotrophin levels.
T: May resolve spontaneously. Non-communicating - reassurance and a scrotal support. Therapeutic aspiration may be required for large hydroceles. An exploratory operation - if unsure on diagnosis, recurrent infections or accumulations, or it is large and uncomfortable. Surgery.

Question 32

Varicocele

Answer 32

An abnormal dilatation of the testicular veins in the pampiniform venous plexus, caused by venous reflux. Well-recognised cause of testicular dysfunction.
C: Caused by defective valves in the veins within the scrotum, just above the testicles. When normal flow doesn’t occur, the blood backs up, causing the veins to dilate.
S: Asymptomatic, scrotum feels like ‘a bag of worms’, scrotal heaviness, scrotum hangs lower, dilation and tortuosity of veins is worse on standing.
D: Sperm count, physical exam, Colour Doppler studies, Venography, Radionucleotide angiography, CT scans, FSH and LH levels.
T: No cure. Bioflavinoids may slow the progress from subclinical to palpable varicoceles. Analgesia. Ligation of blood flow. Surgery - Inguinal/Retroperitoneal/Infra-inguinal or subinguinal/Laparoscopic/Microscopic. Referral to urology.

Question 33

Testicular torsion

Answer 33

It causes occlusion of testicular blood vessels and, unless prompt action is taken, rapidly leads to ischaemia, resulting in loss of the testis.
C: Unknown. Often occurs several hours after vigorous activity, after a minor injury to the testicles or while sleeping. Risk factors: aged between 12-18, previous TT, family history.
S: Sudden, severe pain in one testicle, lower abdo pain, nausea and vomiting, recurrent attacks of pain, swollen, reddening of the scrotal skin.
D: Cremasteric reflex, Ultrasound integrated with colour Doppler, Scintigraphy and dynamic contrast-enhanced subtraction magnetic resonance imaging, urinalysis.
T: Referral to emergency urology or surgical team, analgesia, may be possible to reduce the torsion manually, bilateral orchiopexy is still required after successful detorsion. May need to remove the testicle.

Question 34

Polycystic Kidney Disease

Answer 34

Many fluid-filled sacs develop in the kidneys. The cysts are non-cancerous (benign) and develop from some of the kidney tubules.
The two common problems that develop are high blood pressure and chronic kidney disease (CKD).
Types: autosomal dominant, autosomal recessive, Non-hereditary.
C: Genetics or spontaneous mutation.
S: Asymptomatic, haematuria, proteinuria, back pain, kidney stones, abdominal pain and distension, hypertension, recurrent kidney infections.
D: Ultrasound of the kidneys, CT/MRI scan, urinalysis, renal function tests.
T: Yearly ultrasound, avoid contact sports, avoid anti-inflammatory medications, treat hypertension, analgesia, good lifestyle choices, treat any UTI or AKI, if end-stage kidney disease - kidney dialysis or a kidney transplant.

Question 35

Peyronie’s disease

Answer 35

Inflammatory thickening with fibrin deposition, increased collagen production, decreased quantity of elastic fibres and subsequent fibrosis ± calcification in the penis. Leads to penile angulation.
C: One-off or repeated penile vascular trauma causing leakage and immunological reaction in the relatively avascular tunica albuginea. Genetic predisposition.
S: Penile pain during erections, penile angulation, palpable fibrous plaque, erectile dysfunction.
D: Physical examination, measurement of angulation, International Index of Erectile Function (IIEF), Duplex ultrasonography.
T: May resolve spontaneously (allow several months), external penile traction or vacuum devices, Topical verapamil, electromotive drug administration of dexamethasone, verapamil and/or orgotein and lidocaine, surgery.