Urogenital Flashcards
1
Q
What is renal colic?
A
Pain due to renal calculi (kidney stones)
2
Q
What are renal calculi/kidney stones also known as?
A
Nephrolithiasis
3
Q
Describe the epidemiology of nephrolithiasis
A
- 10% lifetime risk
- More common in men (2:1)
- Higher prevalence in Middle East
4
Q
What are 6 causes of nephrolithiasis?
A
- Urinary (dehydration)
- Infection (proteus, Klebsiella, Pseudomonas)
- Hypercalciuria
- Hyperoxaluria
- Uric acid stones
- Cystine stone
5
Q
What are 6 risk factors for nephrolithiasis?
A
- Chronic dehydration
- Obesity
- High protein/salt diet
- Recurrent UTIs
- Hyperparathyroidism
- Congenital abnormalities
6
Q
Describe the pathophysiology of nephrolithiasis (nucleation theory)
A
- Urine is composed of water (solvent) and particles (solute)
- When solute becomes too concentrated –> supersaturated –> solute precipitates and forms crystals
- Occurs due to an increase in solute or decrease in solvent
7
Q
What commonly occurs in nephrolithiasis?
A
Stones cause obstructions leading to hydronephrosis (one/both kidneys become stretched/swollen due to the build-up of urine inside)
8
Q
What are the 3 most common blockage sites in nephrolithiasis?
A
- Pelviureteric junction (PUJ) - most common
- Pelvic brim
- Vesicoureteric junction (VUJ)
9
Q
What 7 things commonly make up the components of kidney stones/renal calculi?
A
- Calcium oxalate (forms in acidic urine)
- Calcium phosphate (forms in alkaline urine)
- Calcium carbonate
- Struvite (ammonium phosphate)
- Uric acid
- Cystine
- Drug precipitants
10
Q
What is the main symptom of nephrolithiasis?
A
Renal colic:
- Severe unilateral abdominal pain
- Starts in loin and radiates to ipsilateral groin/testicle/labia
- Classically onset and early in the morning
11
Q
What are 4 other symptoms of nephrolithiasis?
A
- Restlessness
- Nausea and vomiting
- Haematuria (blood in urine)
- Dysuria (painful urination)
12
Q
What are 4 investigations for nephrolithiasis?
A
- Non contrast CT KUB (GOLD STANDARD)
- Ultrasound KUB in pregnancy
- Dipstick (haematuria, leucocytes, nitrites)
- Bloods (FBC, CRP, U&Es)
13
Q
What is the treatment for nephrolithiasis?
A
- Small enough stones (<5mm) pass on their own
- ESWL (extracorporeal shock wave lithotripsy - breaks stones into smaller fragments using shockwaves)
- Ureteroscopy PCNL (percutaneous nephrolithotomy - nephroscope used to remove stone)
- Symptomatic relief (NSAIDs/opioids)
- Decrease sodium/protein intake
- Increased citrus fruit
- Rehydration/adequate fluid intake
14
Q
What are 3 complications of nephrolithiasis?
A
- Recurrence is common
- Irreversible renal damage
- Long term blockage can cause sepsis
15
Q
What is acute kidney injury (AKI)?
A
Rapid deterioration of renal function
16
Q
Describe the epidemiology of AKI
A
- 15% of adults admitted to hospital develop AKI
- More common in the elderly
17
Q
What are 8 risk factors of AKI?
A
- HTN
- Volume depletion
- CKD
- Diabetes
- Cirrhosis
- Nephrotoxic medications
- Cancer
- Trauma
18
Q
Describe the pathophysiology of pre-renal AKI
A
Decreased volume = decreased perfusion = decreased GFR and decreased creatinine clearance
19
Q
What are 2 pre-renal causes of AKI?
A
- Low blood volume (bleeding/dehydration/shock/D&V)
- Low effective circulating volume (cirrhosis/congestive HF)
20
Q
Describe the pathophysiology of glomerular intra-renal AKI
A
Barrier damage and protein leakage = decreased oncotic pressure = decreased GFR
21
Q
What is a cause of glomerular intra-renal AKI?
A
Glomerulonephritis
22
Q
Describe the pathophysiology of tubular intra-renal AKI
A
Complex blood supply –> cells infarct –> break away –> plug tubules –> decreased hydrostatic pressure = decreased GFR
23
Q
What are 3 causes of tubular intra-renal AKI?
A
Necrosis:
1. Prolonged ischaemia
2. Infection
3. Nephrotoxins
24
Q
Describe the pathophysiology of interstitial intra-renal AKI
A
Inflammation and immune cells = damage
25
What are 3 causes of interstitial intra-renal AKI?
Acute interstitial nephritis:
1. Infection
2. Ischaemia
3. Connective tissue disease
26
Describe the pathophysiology of vascular intra-renal AKI
- Damaged vasculature = decreased O2 (necrosis)
- Damaged endothelium = RBC breakdown
27
What are 4 causes of vascular intra-renal AKI?
1. Vasculitis
2. Microangiopathic haemolytic anaemia (MAHA)
3. Thrombotic thrombocytopenic purpura (TTP)
4. Haemolytic uremic syndrome (HUS)
28
Describe the pathophysiology of post-renal AKI
Back pressure into tubules = decreased hydrostatic pressure = decreased GFR
29
What are 3 causes of post-renal AKI?
Obstruction:
1. Stones
2. Prostate enlargement (e.g. due to cancer)
3. Infection
30
What are 3 general signs of AKI?
1. High creatinine
2. Arrythmia (due to hyperkalaemia)
3. Pericarditis (due to uraemia)
31
What are 2 signs of pre-renal AKI?
1. Hypotension
2. Oedema
32
What are 2 signs of intra-renal AKI?
1. Infection
2. Signs of underlying disease (vasculitis, glomerulonephritis, DM)
33
What are 2 general symptoms of AKI?
Often asymptomatic
1. Oliguria/anuria (low/no urine output)
2. Muscle weakness (due to hyperkalaemia)
34
What are 3 symptoms of pre-renal AKI?
1. Diarrhoea
2. Nausea and vomiting
3. Syncope/pre-syncope
35
What is a symptom of post-renal AKI?
Lower urinary tract symptoms
36
What are 3 investigations for AKI?
1. Bloods - U&E (eGFR)
2. Creatinine
3. USS/CT KUB
37
What is the NICE guidelines for diagnosis of AKI?
- Rise in serum creatinine of 25 umol/L within 48 hours
- 50% rise in serum creatinine from baseline within 7 days
- Fall in urine output to <0.5 mL/kg/hr for >6 hours
38
What is the treatment for AKI?
- Treat underlying casue
- Fluid balance
- Stop nephrotoxic drugs e.g. NSAIDs, ACEi, metformin, lithium etc.
- Dialysis (if severe)
39
What are 2 complications of AKI?
1. Volume overload
2. Metabolic acidosis
40
What is chronic kidney disease (CKD)?
Long-term, usually progressive impairment of kidney function (>3 months of abnormal kidney structure/function)
41
Describe the epidemiology of CKD
- Between 6-11%
- More common in females
42
What are 7 causes of CKD?
1. Diabetes
2. HTN
3. Age-related decline
4. Glomerulonephritis
5. PKD
6. Obstruction (e.g. kidney stones, enlarged prostate)
7. Medications
43
What are the 4/5 most nephrotoxic types of drugs?
1. Diuretics
2. ACE inhibitors/angiotensin receptor blockers
3. Metformin
4. NSAIDs
44
What are 4 other common nephrotoxic types of drugs?
1. PPIs
2. Lithium
3. Antidepressants
4. Antibiotics
45
What are 6 risk factors for CKD?
1. Diabetes
2. HTN
3. Female
4. Increased age
5. Smoking
6. Nephrotoxic drugs
46
What are 5 signs of CKD?
1. HTN
2. Raised JVP
3. Anaemia
4. Osteomalacia
5. Hyperparathyroidism
47
What are 8 symptoms of CKD?
Often asymptomatic until end-stage
1. Pruritus
2. Loss of appetite
3. Nausea
4. Oedema
5. Muscle cramps
6. Peripheral neuropathy
7. Palpitations
8. Pallor
48
What are 4 investigations for CKD?
1. Bloods - U&E - estimated glomerular filtration rate (eGFR)
2. Urine albumin:creatinine ratio (proteinuria)
3. Urine dipstick (haematuria)
4. Renal ultrasound
49
What is a G score in CKD?
Groupings for eGFR
G1 = >90
G2 = 60-89
G3a = 45-59
G3b = 30-44
G4 = 15-29
G5 <15 (end-stage)
50
What is an A score in CKD?
Groupings for albumin:creatinine ratio
A1 = <3mg/mmol
A2 = 3-30mg/mmol
A3 = >30mg/mmol
51
What is needed for a diagnosis of CKD?
eGFR of at least <60 or proteinuria
52
What is the treatment for CKD?
- Exercise/maintain healthy weight
- Stop smoking
- Dietary restrictions regarding phosphate, sodium, potassium and water intake
- Statins (for primary prevention of CVD)
53
What is the main treatment aim for CKD?
Slow progression
54
What are 6 complications of CKD?
1. Anaemia
2. Renal bone disease (osteodystrophy)
3. Encephalopathy
4. CVD
5. Peripheral neuropathy
6. Dialysis related problems
55
What is a urinary tract infection (UTI)?
Presence of microorganism in the urinary tract
56
Describe the epidemiology of UTIs
More common in women due to shorter urethras
57
What are the 5 most common causes of UTIs?
KEEPS
K - Klebsiella
E - E. Coli (50% of cases)
E - Enterococci
P - Proteus
S - Staphylococcus coagulase negative
58
What are 2 ways in which UTIs are commonly spread?
1. Sexual activity
2. Urinary catheter
59
What does an upper UTI often lead to?
Pyelonephritis (infection and inflammation of the kidney)
60
What 4 things can a lower UTI lead to?
1. Cystitis (infection of urinary bladder)
2. Urethritis (inflammation of urethra)
3. Epididymo-orchitis (inflammation of epididymis and/or testis)
4. Prostatitis (inflammation and swelling of prostate gland)
61
What is an uncomplicated UTI?
- More common/less severe UTI
- Infection in lower urinary tract/bladder/urethra
62
What is a complicated UTI?
- Infection extends beyond bladder to the kidneys
- Present with greater morbidity, carry a higher risk of treatment failure and typically require longer antibiotic courses
63
What are 5 examples of complicated UTIs?
1. Males
2. Pregnancy
3. Result of obstruction
4. Hydronephrosis
5. Colovesical fistula
64
What are 7 clinical presentations of pyelonephritis (upper UTI)?
1. Fever
2. Loin/suprapubic/back pain
3. Malaise
4. Vomiting
5. Loss of appetite
6. Haematuria
7. Renal angle tenderness
65
What are 5 clinical presentations of lower UTIs?
1. Dysuria
2. Suprapubic pain
3. Frequency/urgency
4. Incontinence
5. Confusion
66
What is the investigation for patients with UTIs?
Urine dipstick:
- Nitrites present
- Leukocytes present
67
What is the treatment for UTIs?
Antibiotics:
- First choice = trimethoprim, nitrofurantoin
- Alternatives = pivmecillinam, amoxicillin, cefalexin
68
Which patients for UTIs are given a 3 day course of antibiotics?
Women with simple lower UTIs
69
Which patients for UTIs are given a 5-10 day course of antibiotics?
- Women that are immunosuppressed
- Women that have abnormal anatomy
- Women that have impaired kidney function
70
Which patients for UTIs are given a 7 day course of antibiotics?
- Men
- Pregnant women
- UTIs catheter related
71
What are 3 complications of UTIs?
In pregnancy, increased risk of:
1. Pyelonephritis
2. Premature rupture of membranes
3. Pre-term labour
72
What is nephritic syndrome?
Inflammation within the kidney defined by haematuria, oliguria, proteinuria and hypertension
73
What are 4 systemic causes of nephritic syndrome?
1. Systemic lupus erythematosus
2. Post-streptococcal glomerulonephritis
3. Small vessel vasculitis (Henoch Schoenlein pupura)
4. Goodpasture's/anti GBM
74
What is a renal cause of nephritic syndrome?
IgA nephropathy (most common cause in UK/high income countries)
75
Describe the pathophysiology of nephritic syndrome
- Inflammation cause podocytes to develop large pores
- This allows blood flow into the urine
76
What are 3 investigations for patients with nephritic syndrome?
1. Urine dipstick (haematuria)
2. Bloods (elevated ESR and CRP)
3. Kidney biopsy (to find cause)
77
What is the treatment for nephritic syndrome?
- Treat underlying cause
- ACE inhibitors/angiotensin receptor blockers (to reduce proteinuria and preserve renal function)
- Corticosteroids (to reduce inflammation and damage)
78
What are 2 complications of nephritic syndrome?
1. AKI
2. Decreased resistance to infection
79
What is IgA nephropathy (a.k.a Berge Disease)?
Deposition of IgA into the mesangium of the kidney (component of glomerulus) causing inflammation and damage
80
How does IgA nephropathy present?
Asymptomatically with microscopic haematuria
81
How is IgA nephropathy diagnosed and treated?
- Biopsy
- Treatment the same as nephritic syndrome
- Fish oil and steroids given if persistent proteinuria after 3-6 months
82
What is Goodpasture's disease/anti GBM disease?
Autoimmune disease - autoantibodies (anti-glomerular basement membrane) to type IV collagen in glomerular and alveolar membrane
83
How does Goodpasture's disease/anti GBM disease present?
SOB and oliguria
84
How is Goodpasture's disease/anti GBM disease diagnosed and treated?
- Anti-GBM antibodies in blood and biopsy
- Plasma exchange, steroids and cyclophosphamide (immune suppression)
85
What is post-streptococcal glomerulonephritis?
Nephritic syndrome following an infection 3-6 weeks prior due to the deposition of strep antigens in glomeruli causing inflammation and damage
86
How does post-streptococcal glomerulonephritis present?
Haematuria and acute nephritis
87
How is post-streptococcal glomerulonephritis diagnosed and treated?
- Find evidence of strep infection (e.g. positive throat swab results)
- Antibiotics to clear strep and supportive care
88
What is Henoch Schoenlein purpura?
Small vessel vasculitis that affects the kidney and joints due to IgA deposition
89
How does Henoch Schoenlein purpura present?
Purpuric rash on legs, nephritis symptoms and joint pain
90
How is Henoch Schoenlein purpura diagnosed and treated?
- Diagnosis confirmed with renal biopsy
- Treated the same as nephritic syndrome = ACE inhibitors/angiotensin receptor blockers and corticosteroids
91
What is nephrotic syndrome?
Increased permeability of glomerular basement membrane to proteins
92
Describe the epidemiology of nephrotic syndrome
- Most common in children aged 2-5
- Twice as common in men
93
What are 3 primary causes of nephrotic syndrome?
1. Minimal change disease (25% of adult causes and most common cause in children)
2. Focal segmental glomerulosclerosis
3. Membranous nephropathy (25% of adult cases)
94
What are 5 secondary causes of nephrotic syndrome?
DDANI
D - Diabetes
D - Drugs
A - Autoimmune
N - Neoplasia
I - Infection
95
Describe the pathophysiology of nephrotic syndrome
- Issue with filtration barrier
- Podocytes are primarily implicated and develop gaps
- Protein is able to leak into the urine
96
What are 5 clinical presentations of nephrotic syndrome?
1. FROTHY URINE
2. OEDEMA
3. Pallor
4. Hypoalbuminemia
5. Hyperlipidaemia
97
What are 4 investigations for patients with nephrotic syndrome?
1. Urine dipstick (proteinuria >3+ protein)
2. Urine protein:creatinine ratio
3. Bloods (renal function, elevated lipids, low serum albumin)
4. Renal biopsy
98
What is the treatment for nephrotic syndrome?
- Treat cause
- Manage complications
- Fluid and salt restriction
- Loop diuretics
- ACE inhibitors/ARB
99
What are 2 complications of nephrotic syndrome?
1. Hyperlipidaemia (loss of albumin = increased cholesterol - managed with statins)
2. Venous thromboembolism (increase clotting factors - manage with heparin)
100
How is minimal change disease diagnosed and treated?
- Normal appearance upon microscopy but abnormal function
- Biopsy
- Treat with high dose steroids e.g. prednisolone
101
What are 4 causes of focal segmental glomerulosclerosis?
1. Idiopathic
Secondary to:
2. HIV
3. Heroin
4. Lithium
102
How is focal segmental glomerulosclerosis diagnosed and treated?
- Presence of scarring of glomeruli i.e. focal sclerosis
- Blood pressure control = ACE inhibitors/ARB (all)
- Steroids (idiopathic)
103
Describe membranous nephropathy
Immunologically mediated
104
How is membranous nephropathy diagnosed and treated?
- Renal biopsy (thickened glomerular basement membrane)
- Anti-phospholipase A2 receptor antibody found in 70-80% of patients
- ACE inhibitors/ARB (all)
- Prednisolone and cyclophosphamide (in patients with a high risk of progression)
105
What is diffuse proliferative glomerulonephritis?
Histological form of renal injury commonly seen in patients suffering from autoimmune disease
106
How does diffuse proliferative glomerulonephritis present?
Can present as either nephritic or nephrotic syndrome
107
What are the investigations for patients with diffuse proliferative glomerulonephritis?
Microscopy:
- Mesangial and endothelial cell proliferation
- Polymorphonuclear cell infiltrate
- Granular subepithelial deposits of C3 and immunoglobulins
- Swollen glomeruli
108
What is membranoproliferative glomerulonephritis?
Kidney disorder involving inflammation and changes to kidney cells
109
What is involved in all types of membranoproliferative glomerulonephritis?
Nephritic factor
110
Describe the pathophysiology of type I membranoproliferative glomerulonephritis
- Circulating immune complexes form due to antigen release from a chronic infection e.g. Hep B/C
- Bound by antibodies in the blood
- Travel to glomerulus and activates complement pathway
- = deposition of immune complexes and complement
- Basement membrane thickening
111
Describe the pathophysiology of type II membranoproliferative glomerulonephritis
- Complement deposits
- No immune complexes
112
Describe the pathophysiology of type III membranoproliferative glomerulonephritis
Immune complex and complement deposits in subendothelial and subepithelial spaces
113
How does membranoproliferative glomerulonephritis present?
Can present as either nephritic or nephrotic syndrome
114
What are 2 investigations for patients with membranoproliferative glomerulonephritis?
1. Tram track on light microscopy
2. Granular on immunofluorescence
115
How is membranoproliferative glomerulonephritis treated?
Corticosteroids
116
What is benign prostatic hyperplasia?
Hyperplasia of inner transitional zone of prostate gland without malignancy
117
Describe the pathophysiology of benign prostatic hyperplasia
- Glandular epithelial cells and stroma cells undergo hyperplasia
- Median lobe usually affected
118
What are 3 storage symptoms of benign prostatic hyperplasia?
1. Frequency/urgency
2. Nocturia
3. Urgency incontinence
119
What are 5 voiding symptoms of benign prostatic hyperplasia?
1. Weak/intermittent stream
2. Post-micturition dribbling
3. Straining
4. Incomplete emptying
5. Hesitancy
120
What are the 2 main investigations for patients with benign prostatic hyperplasia?
1. Digital rectal examination (DRE) = smooth but enlarged prostate
2. Prostate-specific antigen test (PSA) = raised
121
Why are PSA tests unreliable?
High rate of false positives (75%) and negatives (15%)
122
What are 6 things that may cause a patient's PSA to be raised?
1. Prostate cancer
2. Benign prostatic hyperplasia
3. Prostatitis
4. Urinary tract infections
5. Vigorous exercise (notably cycling)
6. Recent ejaculation or prostate stimulation
123
What are 2 other investigations that may be used for patients with benign prostatic hyperplasia?
1. Bladder diaries
2. Ultrasound
124
What is the treatment for benign prostatic hyperplasia?
- Reduce caffeine/alcohol intake
- Alpha blockers e.g. doxazosin, tamsulosin
- 5-alpha reductase inhibitor e.g. finasteride
- Surgery - transurethral resection of prostate (TURP)
125
What do alpha blockers do?
Relax the smooth muscle in the neck of the bladder and prostate - for patients with severe voiding problems
126
What do 5-alpha reductase inhibitors do?
Block the conversion of testosterone to dihydrotestosterone and therefore decreases the size of the prostate
127
Why may surgery be required in patients with benign prostatic hyperplasia?
- If prostate fails to respond to treatment
- If there is acute urinary retention
- If there is gross haematuria
- If it spreads to the kidneys
128
What are 2 complications of benign prostatic hyperplasia?
1. Recurrent UTI
2. Bladder calculi
129
Describe the epidemiology of prostate cancer
Most common cancer in men
130
What are 5 risk factors for prostate cancer?
1. Increasing age
2. Family history
3. Black African or Caribbean origin
4. Tall stature
5. Anabolic steroids
131
Describe the pathophysiology of prostate cancer
- Almost always androgen dependent
- Majority are adenocarcinomas and grow in peripheral zone of prostate
- Advanced prostate cancer commonly spreads to lymph nodes and bones
132
What are 4 symptoms of prostate cancer?
Can be asymptomatic
1. LUTS e.g. hesitancy, frequency/urgency, weak flow, dribbling, nocturia
2. Haematuria
3. Erectile dysfunction
4. Symptoms of metastasis e.g. weight loss/bone pain
133
What are 5 investigations for patients with prostate cancer?
1. DRE
2. PSA test
3. Transrectal USS
4. Biopsy
5. Gleason grading system
134
What are the result of a DRE in patient with prostate cancer?
Prostate feels firm/hard, asymmetrical and craggy with loss of a central sulcus
135
What is the Gleason grading system?
- Based on histology from prostate biopsies
- Greater score (1-5) = worse prognosis
136
What is the treatment for patients with prostate cancer?
- Prostatectomy
- Hormone therapy
- Radiotherapy
- Chemotherapy
137
What are 3 types of hormone therapy used in patients with advanced prostate cancer?
1. Goserelin (zoladex) or leuprorelin (prostap) = GnRH agonists
2. Bicalutamide = androgen-receptor blocker
3. Bilateral orchidectomy
138
Describe the epidemiology of testicular cancer
- More common in younger men (15-35)
- 98% 5 year survival
139
What are 6 risk factors for testicular cancer?
1. Caucasian
2. HIV
3. Undescended testis (cryptorchidism)
4. Male infertility
5. Family history
6. Increased height
140
Describe the pathophysiology of testicular cancer
- 90% arise from germ cells in the testes (seminomas, teratoma, choriocarcinoma)
- Non-germ cell tumours (sertoli, leydig, lymphoma, mesenchymal)
- Commonly metastasises to lymphatics, lungs, liver, brain
141
What are 4 clinical presentations of testicular cancer?
1. Painless lump on testicle
2. Hydrocele (swollen scrotum)
3. Gynaecomastia
4. Haematospermia
142
Describe a painless lump in patients with testicular cancer
- Non tender
- Hard
- Irregular
- Not fluctuant
- No transillumination
143
What are 2 investigations for patients with testicular cancer?
1. Scrotal ultrasound
2. Tumour markers = alpha-fetoprotein, beta-Hcg, lactate dehydrogenase (LDH)
144
What is the treatment for testicular cancer?
- Surgery (orchidectomy)
- Chemotherapy
- Radiotherapy
145
What is a complication of testicular cancer?
Infertility (sperm banking often used to save sperm for future use)
146
Describe the epidemiology of bladder cancer
- Most common GU tract malignancy
- 10th most common cancer
- 3% of all cancer deaths
- More common in men
147
What are 6 risk factors for bladder cancer?
1. Smoking
2. Age over 55
3. Male
4. Caucasian
5. Previous pelvic radiotherapy
6. Exposure to aromatic amines (carcinogen in dye/rubber/cigarette smoke)
148
Describe the pathophysiology of bladder cancer
- Most common type is transitional cell carcinoma (90%)
- Arise from transitional cells of mucosal urothelium
- Most commonly metastasises to lymph nodes, bones, lungs, liver
149
What are 4 other types of bladder cancer?
1. Squamous cell carcinoma (5% - higher in areas of schistosomiasis)
2. Adenocarcinoma (2%)
3. Sarcoma (rare)
4. Small cell carcinoma (rare)
150
What are 4 symptoms of bladder cancer?
1. PAINLESS HAEMATURIA
2. Urgency
3. Suprapubic pain
4. Symptoms of systemic spread e.g. bone pain, weight loss
151
What are 3 investigations for patients with bladder cancer?
1. Cystoscopy and biopsy
2. Urinalysis
3. Bloods
152
What is the treatment for bladder cancer?
- Radiotherapy
- Chemotherapy
- Surgery = transurethral resection of bladder tumour (TURBT), cystodiathermy (excision of small lesions of bladder), cystectomy (removal of bladder)
153
Describe the epidemiology of renal cancer
- Mean age of diagnosis = 55
- Twice as common in men
154
What are 7 risk factors for renal cancer?
1. Smoking
2. Obesity
3. Hypertension
4. End-stage renal failure
5. Von Hippel-Lindau disease
6. Tuberous sclerosis
7. Family history
155
Describe the pathophysiology of renal cancer
- Most common type is renal cell carcinoma (90%) (arises from proximal convoluted tubular epithelium)
- Can secrete PTH, ACTH, EPO and renin
- Also transitional cell carcinoma (arises from renal pelvis)
- Both commonly metastasise to lymph system, lung, breast and skin
156
What are 5 clinical presentations of renal cancer?
Renal cell carcinoma - often asymptomatic
Classic triad of presentation:
1. Vague loin pain
2. Haematuria
3. Abdominal mass
4. Anorexia/weight loss
5. Varicocele
157
What are 6 investigations for patients with renal cancer?
1. Ultrasound = 1st line
2. CT chest/abdomen/pelvis
3. Other imaging e.g. CT/MRI/CXR
4. Renal biopsy
5. Bloods (polycythaemia)
6. Raised BP
158
What is the treatment for renal cancer?
Total/partial nephrectomy
159
What are 4 complications of renal cancer?
Paraneoplastic changes:
1. Polycythaemia
2. HTN
3. Hypercalcaemia
4. Cushing's
160
What is polycystic kidney disease (PKD)?
Inherited condition where clusters of fluid-filled cysts develop within the kidneys
161
Describe the epidemiology of PKD
- Autosomal dominant presents after 20s (any age) and is more common than autosomal recessive
- Autosomal recessive typically presents at birth
162
Describe the pathophysiology of PKD
- Cysts develop (recessive - born with) and grow over time in tubular portion of kidney
- Leads to compression of renal parenchyma and vasculature
- Progressive impairment
163
Which genes are affected in PKD?
Autosomal dominant:
- PKD-1 = chromosome 16 (85% of cases)
- PKD-2 = chromosome 4 (15% of cases)
Autosomal recessive:
- Chromosome 6
164
What are 4 clinical presentations of PKD?
Asymptomatic
1. HTN
2. Bilateral flank/back/abdominal pain
3. Headache
4. LUTS
165
What is a common presentation of autosomal recessive PKD?
Oligohydramnios (lack of amniotic fluid) which leads to underdevelopment of lungs resulting in resp failure shortly after birth
166
What are 3 investigations for PKD?
1. Kidney USS
2. Renal biopsy
3. Genetic testing
167
What is the treatment for PKD?
- Tolvaptan (vasopressin receptor antagonist - slows cyst development)
- Antihypertensives
- Analgesia
- Renal replacement therapy for end-stage renal failure
168
What are 7 complications of PKD?
1. Berry aneurysms (intracranial aneurysms that present as sub arachnoid haemorrhages)
2. Chronic back pain
3. HTN
4. CVD
5. Haematuria
6. Kidney stones
7. End-stage renal failure
169
What is chlamydia?
Bacterial infection caused by gram-negative bacteria chlamydia trachomatis
170
Describe the epidemiology of chlamydia
Most common bacterial STI
171
Describe the pathophysiology of chlamydia
- Chlamydia trachomatis
- Intracellular organism
- Enters and replicates within cells before rupturing the cell and spreading to others
172
How does chlamydia present in men?
- 50% asymptomatic
- Testicular pain
- Dysuria
- Urethral discharge/discomfort
173
How does chlamydia present in women?
- 70% asymptomatic
- Vaginal discharge (white/yellow/green)
- Dysuria
- Abnormal vaginal bleeding
- Dyspareunia (painful sex)
174
What are the 2 swabs used to investigate patients with chlamydia?
- Charcoal swab (allows for microscopy, culture and sensitivities)
- Nucleic acid amplification testing (NAAT - checks directly for DNA/RNA of organism)
175
How are swabs most commonly collected in patients with chlamydia?
- Vulvovaginal swab (women)
- Urethral swab (men)
- First-catch urine sample (both)
176
What are 4 things usually found on examination in patients with chlamydia?
1. Pelvic/abdominal tenderness
2. Cervical motion tenderness
3. Inflamed cervix
4. Purulent discharge
177
What is the standard treatment and advice for chlamydia?
- Doxycycline 100mg twice a day for 7 days
- Avoid sex until treatment is complete
178
When can doxycycline not be used to treat chlamydia?
Contraindicated in pregnancy and breastfeeding
179
What are 3 alternative drugs used to treat chlamydia?
- Azithromycin
- Erythromycin
- Amoxicillin
180
What are 5 complications of both chlamydia and gonorrhoea?
1. Infertility
2. Pelvic inflammatory disease
3. Chronic pelvic pain
4. Epididymo-orchitis
5. Conjunctivitis
181
What are 2 other complications of chlamydia?
1. Lymphogranuloma venerum
2. Reactive arthritis
182
What are 6 pregnancy-related complications of chlamydia?
1. Pre-term delivery
2. Premature rupture of membranes
3. Low birth weight
4. Postpartum endometritis
5. Neonatal infection e.g. conjunctivitis, pneumonia
6. Ectopic pregnancy
183
What is gonorrhoea?
Bacterial infection caused by gram-negative diplococcus bacteria Neisseria gonorrhoea
184
Describe the epidemiology of gonorrhoea
2nd most common STI in the UK
185
Describe the pathophysiology of gonorrhoea
- Infects mucous membranes with a columnar epithelium e.g. endocervix, urethra, rectum, conjunctiva and pharynx
- Spread via contact with mucous secretions from infected areas
186
How does gonorrhoea present in men?
- 10% asymptomatic
- Odourless purulent discharge (green/yellow)
- Dysuria
- Testicular pain/swelling (epididymo-orchitis)
187
How does gonorrhoea present in women?
- 50% asymptomatic
- Odourless purulent discharge (green/yellow)
- Dysuria
- Pelvic pain
188
What are 4 common presentations of gonorrhoea?
1. Rectal infection (anal/rectal discomfort)
2. Pharyngeal infection (sore throat)
3. Prostatitis (perineal pain, urinary symptoms, prostate tenderness)
4. Conjunctivitis (erythema, purulent discharge)
189
What are the 2 swabs used to investigate patients with gonorrhoea?
- Charcoal swab (allows for microscopy, culture and sensitivities)
- Nucleic acid amplification testing (NAAT - checks directly for DNA/RNA of organism)
190
How are swabs most commonly collected in patients with gonorrhoea?
- Vulvovaginal swab (women)
- Urethral swab (men)
- First-catch urine sample (both)
- Rectal and pharyngeal swabs (recommended in all men who have sex with men - MSM)
191
What is the first line treatment for gonorrhoea?
Single dose of intramuscular ceftriaxone 1g
192
Why can there be difficulty in treating gonorrhoea?
High levels of antibiotic resistance i.e. ciprofloxacin or azithromycin
193
What are 7 other complications of gonorrhoea?
1. Prostatitis
2. Urethral stricture
3. Disseminate gonococcal infection
4. Skin lesions
5. Fitz-Hugh-Curtis syndrome
6. Septic arthritis
7. Endocarditis
194
What is syphilis?
Bacterial infection caused by spirochete Treponema pallidum
195
Describe the pathophysiology of syphilis
- Bacteria gets in through skin or mucous membranes
- Replicates and disseminates throughout body
- Incubation period between initial infection and symptoms = 21 days on average
196
What are 4 methods of transmission for syphilis?
1. Oral/vaginal/anal sex
2. Vertical transmission
3. IV drug use
4. Blood transfusions/transplants
197
How does primary syphilis present?
- Painless ulcer (chancre) at original site of infection (tends to resolve over 3-8 weeks)
- Local lymphadenopathy
198
How does secondary syphilis present?
- Maculopapular rash
- Condylomata lata (grey wart-like lesions around genitals/anus)
- Low-grade fever
- Lymphadenopathy
- Alopecia
- Oral lesions
- Symptoms resolve after 3-12 weeks
199
What is latent syphilis?
Patient is asymptomatic but still infected
200
How does tertiary syphilis present?
- Occurs many years after initial infection
- Development of gummas (granulomatous lesions)
- Aortic aneurysms
- Neurosyphilis
201
How does neurosyphilis present?
- Headache
- Altered behaviour
- Dementia
- Tabes dorsalis
- Ocular syphilis
- Paralysis
- Sensory impairment
202
What are 3 investigations for patients with syphilis?
1. Antibody testing (antibody to T. pallidum bacteria)
2. Dark field microscopy (for T. pallidum bacteria)
3. Polymerase chain reaction (PCR - for T. pallidum)
203
What is the 1st line treatment for syphilis?
Single intramuscular dose of benzathine benzylpenicillin
204
What are 3 alternative drugs used to treat syphilis?
1. Ceftriaxone
2. Amoxicillin
3. Doxycycline
205
What is a varicocele?
An abnormally dilated testicular vein in pampiniform venous plexus
206
Describe the epidemiology of varicocele
- Affects around 15% of men
- 90% occur on the left side
- Incidence increases after puberty
207
What are 2 causes of varicocele?
1. Venous reflux (due to incompetent valves)
2. Left can indicate an obstruction due to renal cell carcinoma
208
Describe the pathophysiology of varicocele
- Impaired venous drainage leads to increased resistance and venous pressure
- = vein dilatation
- Increased resistance in the left testicular vein therefore is more commonly affected
209
Describe the effects of varicocele on sperm
- Pampiniform plexus is involved in regulating the blood temperature to ensure that it is the optimum temperature required to produce sperm
- Varicoceles generate heat which can affect sperm quality by reducing the proteins required for healthy sperm
210
What are 2 signs of varicocele?
1. Scrotal mass that feels like 'a bag of worms'
2. Asymmetry in testicular size
211
What are 2 symptoms of varicocele?
1. Dragging/soreness/heaviness of scrotum
2. Throbbing/dull pain/discomfort (worse on standing and usually disappears when lying down)
212
What are 3 investigations for patients with varicocele?
1. USS with Doppler imaging
2. Semen analysis (if concerned about fertility)
3. Hormonal tests e.g. FSH and testosterone (if concerned about function)
213
What is the treatment for varicocele?
- Conservative management for uncomplicated cases
- Surgical repair if pain
214
What are 2 complications of varicocele?
1. Infertility
2. Testicular atrophy
215
What is a hydrocele?
Collection of fluid within the tunica vaginalis
216
What are 5 causes of hydrocele?
1. Idiopathic
2. Testicular cancer
3. Testicular torsion
4. Epididymo-orchitis
5. Trauma
217
What is the difference between a simple, communicating and non-communicating hydrocele?
Simple = overproduction of fluid, common at birth (usually disappears within first 2 years of life)
Communicating = connection between scrotum and peritoneal fluid
Non-communicating = imbalance between secretion and reabsorption of fluid
218
What are 4 signs of a hydrocele?
1. Testicle is palpable within hydrocele
2. Testicle is soft, fluctuant and may be swollen
3. Irreducible and has no bowel sounds (distinguish from hernia)
4. Transilluminated
219
What is a symptom of a hydrocele?
Usually painless but may be some pain
220
What are 2 investigations for hydrocele?
1. Examination - palpate and transilluminate
2. USS
(Rule out testicular cancer)
221
What is the treatment for hydrocele?
- Most idiopathic hydroceles resolve spontaneously (manage conservatively)
- Surgery/aspiration/sclerotherapy may be required for large/symptomatic cases
222
What is a complication of hydrocele?
Infection
223
What is testicular torsion?
Medical emergency! Torsion of spermatic cord
224
Describe the epidemiology of testicular torsion
Most commonly affects teenage boys
225
What is the cause of testicular torsion?
Trauma
226
Describe the pathophysiology of testicular torsion
Occlusion of testicular blood vessels
227
How does a testicular appendage torsion differ from testicular torsion?
- Twisting of vestigial appendage along testicle (has no function)
- Only thing that needs to be managed is pain if any
228
What are 5 signs of testicular torsion?
1. Firm, swollen testicle
2. Elevated/retracted testicle
3. Absent cremasteric reflex
4. Abnormal testicular lie (often horizontal)
5. Prehn's sign negative
229
What is a cremasteric reflex?
Stroking of inner thigh causes cremaster muscle to contract and pull ipsilateral testicle up towards inguinal canal
230
What is Prehn's sign?
Lift the scrotum and observe if there is any change in pain
positive = pain eased
negative = no change
231
What are 3 symptoms of testicular torsion?
1. Acute rapid onset of unilateral testicular pain (often following sports/physical activity)
2. May have abdominal pain
3. May be vomiting
232
What are 2 investigations for patients with testicular torsion?
1. Examination
2. Scrotal ultrasound (whirlpool sign - spiral appearance to spermatic cord and blood vessels)
233
What is the treatment for testicular torsion?
- De-torsion
- Analgesia
- Orchidectomy if necrosis
234
What are 2 complications of testicular torsion?
1. Ischaemia/atrophy and necrosis of testicle
2. Infertility
235
What is an epididymal cyst?
An extra-testicular spherical cyst in the head of the epididymis
236
What is a spermatocele?
Epididymal cyst containing sperm (identical presentation/treatment to epididymal cyst)
237
Describe the epidemiology of epididymal cysts
- Occur in around 30% of men
- Most common cause of scrotal swelling
238
What are 3 signs of epididymal cysts?
1. Smooth, round lump typically at top of testicle
2. Cyst and testes can be palpated separately
3. Transilluminates (contains clear and milky fluid)
239
What are symptoms of epididymal cysts?
Usually asymptomatic
240
What are 2 investigations for epididymal cysts?
1. Examination
2. May be found incidentally on ultrasound
241
What is the treatment for epididymal cysts?
Usually none required - usually dissolve within 10 days
242
What is a complication of epididymal cysts?
Torsion of cyst (extremely rare)
243
What are 4 LUTS (storage)?
1. Frequency
2. Urgency
3. Nocturia
4. Incontinence
244
What are 5 LUTS (voiding)?
1. Straining
2. Hesitancy
3. Incomplete emptying
4. Post-micturition dribbling
5. Poor stream
245
What are the two types of urinary incontinence?
Urge = overactivity of detrusor muscle of bladder
Stress = weakness of pelvic floor and sphincter muscles
246
How do urge and stress incontinence differ in their presentation?
Urge = sudden urge to urinate (often urinate before reaching a bathroom)
Stress = urine leaks at times of increased pressure on bladder e.g. when laughing/coughing/surprised
247
How is urge incontinence managed?
- Bladder retraining
- Anticholinergic medications e.g. oxybutynin
- Mirabegron
- Invasive procedures (if failure to respond to retraining/medication)
248
What are 4 invasive procedures used to treat urge incontinence?
1. Botulinum toxin type A injection into bladder wall
2. Percutaneous sacral nerve stimulation
3. Augmentation cystoplasty
4. Urinary diversion
249
How is stress incontinence managed?
- Avoid caffeine/diuretics
- Avoid excessive or restricted fluid intake
- Weight loss if appropriate
- Supervised pelvic floor exercises
- Surgery
- Duloxetine (if surgery less preferred)
250
What are 4 surgical procedures used to treat stress incontinence?
1. Tension-free vaginal tape (TVT)
2. Autologous sling procedures
3. Colposuspension
4. Intramural urethral bulking
251
What is mixed incontinence?
Combination of urge and stress incontinence
252
What are 8 risk factors for urinary incontinence?
1. Increased age
2. Postmenopausal status
3. Increased BMI
4. Previous pregnancies/vaginal deliveries
5. Pelvic organ prolapse
6. Pelvic floor surgery
7. Neurological conditions e.g. multiple sclerosis
8. Cognitive impairment and dementia
253
What is overflow incontinence?
Chronic urinary retention due to an obstruction to outflow of urine (unable to fully empty bladder so causes frequent leaking)
254
Describe the epidemiology of overflow incontinence
More common in men
255
What are 4 causes of overflow incontinence?
1. Anticholinergic medications
2. Fibroids
3. Pelvic tumours
4. Neurological conditions e.g. multiple sclerosis, diabetic neuropathy and spinal cord injuries
256
What is urinary retention?
Inability to empty urine from bladder
257
What are 5 causes of urinary retention?
1. Lower urinary tract obstruction
2. Benign prostatic hyperplasia
3. Pelvic organ prolapse
4. Urinary tract stones (calculi)
5. Constipation
