Urogenital Flashcards
what are the antidotes to teh following drug overdoses - Anti-freeze (ethylene glycol) poisoning –
Cyanide poisoning –
Lead poisoning –
Organophosphate poisoning – A
Heparin overdose –
Anti-freeze (ethylene glycol) poisoning – Ethanol
Cyanide poisoning – Dicobalt edetate
Lead poisoning – Sodium calcium edetate
Organophosphate poisoning – Atropine
Heparin overdose – Protamine sulphate
Nephrolithiasis definition
the prescence of stones in teh renal system
Nephrolithiasis epidemiology
- Typically 30-60 years old
- M>F
50% lifetime risk of reoccurrence
Nephrolithiasis risk factors
- Dehydration
- Previous stones
- stone forming foods
- Genetic - renal tubular acidosis
- Metabolic - hypercalcaemia, hyper parathyroidism, hypercalciuria
Family history
Nephrolithiasis pathophysiology
- Solutes in the urine precipitate and crystalise and form a stone. Substances like magnesium and citrate inhibit the crystal growth
- Calcium oxalate is the most common renal stone formation - acidic urine
- Calcium phosphate - more liley to form in alkalaine urein
- Uric acid - this doesn’t show up on x ryas
Nephrolithiasis signs and symptoms
Flank f=tenderness
Fever
Hypotenstion and tachycardia f the stine is septic
Sevrer loint ot groin pain
Fluctuating in severity
N%V
Urinary urgancy and frequancy
Heamatauria
Oligurina
Fever if its septic
Nephrolithiasis 1st line tests
- Urinanalysis for haematuria
- Inflamatory markers 0 raised WBC and CRP
- U &E - riased creaties suggets AKI due to obstruction
Bone sprofie and urate - elevated calcoum may show yperperparathyroidism
CT urogram fr diagnosing
Nephrolithiasis differenctils
Rubtured abdominal aortic anyerism
Apperdicitis
Ectpic pregnancy
Ovarian cyst
Bowel obstruction
Diverticulits
Nephrolithiasis treatment
Acute:
* IV fluids and antiemetics
* NSAID, then paracetamol secondary
* Antibiotics if there is an infection present
Surgical:
* Ureteroscopy - ureteeroscope into the ureter and retrieve the stone with intracoporeal lithotripsy
* Extracorporeal shock wave lithotripsy - high energy sound waves to break down the stones fomr outside of the body
* Percutaneous nephrolithotomy - surgical inscision in the bac for intracorporal lithoptripsy
* Uretal stention
Nephrolithiasis monitering
- Increases oral fluids
- Rediced dietry salt intake
- Reduce oxalate rich foods for calcium stones - spinach , nutsm tea
- Reduce intake of urate high stones - kidney, liver, sardines
Acute kidney injury definition
sudden decline in kidney function over a few days
Acute kidney injury causes
Pre-Renal –
* Sepsis
* Dehydration
* Hemorrhage
* Cardiac failure
* Liver failure
* Renal artery stenosis
Intra-renal –
* Nephrotoxins
* Parenchymal disease etc Multiple myeloma
Post-Renal –
* Ureteric
* Retroperitoneal Fibrosis
* Bilateral renal stones
* Tumors
* Bladder
* Acute Urinary Retention
* Blocked catheter
* Urethral
* Prostatic enlargement
* Renal stones
Acute kidney injury risk factors
65 >=
Pre-existing kidney problem
Dehydrated
Blockage in your urinary tract
Sepsis
Immunocompromise
Toxins
Hypovolemia
Acute kidney injury pathophysiology
Pre renal -
* Hypofusion due to hypovolemua due to: cardiac faliure, hypoalbuimneria. The lack of blood causes ischemia and damage
Intrinsic -
* Vascular damage - athersclarosis, thrombusus, dissections,
* Glomerular damage - can lead to nephritic syndreom
* Tubulo interstitial due toi necrosis, can be secondary to medications or infectino based
Post renal -
Onstruction - urinary stones, malignayc, strictures
Acute kidney injury key presintations
- Feeling sick
- Diarrhoea
- Dehydration
- Confusion
- Drowsiness
- Reduced capillery refill - if hypovolemic cause
- Tachycardia
- OLIGAURIA - less weeeeee
- Postural hypotension
There are two classification systems
* RIFLE - the last 2 are turned into chornic
* You measure creatine and urine output
*
* KDIGO - says tha causes kidney disease is an increases in serum creatine >26.5 in 48 hours,
- An increase in serum creatinine to ≥ 1.5 times baseline within 7 days
- Urine output < 0.5 mL/kg/hr for six hours
Acute kidney injury fist line test
- Serum creatinine test - acute rise
- Fbc - high ER might siggest vasculitis, serum calcium, phosphate and ruic acid for kidney stones
- Urineanalysis - blood, nitrates, leukocytes, proteins
- reanl ultrasound to ook for kidney stones
- Monitor kidney output
- Urine and blood cultures to exclude infection
Acute kidney injury treatment
Treat the underlying causes -
* Prerenal - correct fluid depletion, treat sepsis with antibiotics
* Renal - refer to nephrology
* Post renal - cathaterise and consider CT KUB
* Stop any nephrotoxis drugs NSAIDS, ACE inhibitors, gentamcin, amphotecterin * Treat hyperkalaema, pulmonary oedema, uraremia and acidaemia * Dialysis to remove toxins form the body Drig over dose - barbiturate, lithium, alcohol-ethylene glycol, salicylate, theophylline
Acute kidney injury complications
Hyperkalaemia!! This is associated with tall peaked T waves, wides QRS, small p waves. To manage give insulin and dextrose to drive the K+ fomr the blood into the cells, gve salbutamol and IV fluids
chronic kidney disease definition
Long standing progressive abdormailty of kidney function - a reduction in GFR <60ml/min/173M^2 for longer than 3 months
chronic kidney disease epidemiology
6-11% of people have CKD
F>M
chronic kidney disease causes
- Hypertension- the walls thinken to withstand the pressre whhc leads t a narrow lumen, less bloood fow, ischeamia. The ischeami leads to glumerulosclarosis (hardening and scarring) which leads to dimined siltering ability
- Diabeties - excess glucose sticks to protiens and make it stiff and narrow, it cuases obstruction which leadst o hyerfiltrtoin ang glomerulosclerosis
- Polyscystc kidney disease
- Any glomerular disease - IgA nephropathy, wegeners granulomatosis, amyloydosis, nephrotic syndrome
- Chronic NSAID use
- SLE
- Nephrotoxic drugs
- Meloma
Enlarged prostate/kidney stone
chronic kidney disease risk factors
- Diabeties,
- Hypertnsion
- SLE
- Female gender
- Smoking
- lV hypertrophy
Family history
chronic kidney disease pathophysiology
- CKD leads to end stage kidney disease
- The speed of decline depends on the nephropathy and BP control
- Sine of the nephrons die which leavs a harder job to the other nephrins who need to make up for it, which causes hypertrophy and reduced arterilar resistance
This increased pressure and strain accelerated the nephron failing
chronic kidney disease signs
- Small kidneys on ultrasoun
- Pallor
- Hypertension
- Peripheral oedema
- Pleural effusion
- lV hypertrophy
chronic kidney disease symptoms
- Urinary changes - oligureia, polyurina, protinuria, haematuria, nocturia
- Non specitfic - tremor, malaise, nausea, hiccpus, legarthy
- Bone diseases - causes by lack of 25-dehydroxyvitamin D leading to excess PTH to be release to make up for a lack of calcium leading to pseudofractures and pain
- Anaemia - less EPO, the liver makes hepdacin which the kidneys wxcrete which leads to a build up and reductiong of intestinal iron absorbtion
- Hyperkaleamia - weakness and paralyis, metabolic acidosis, cardiac arrhythmias
- Cardiovascualr disease - ureamic pericarditis, hypertension, peripheral vascualr disease
- Neurologila - confusion, coma, fits
- Colume overload - dyspnea, oedema
Sexual dysfunction
chronic kidney disease test
- FBC - aanaemia, creatin and urea, decreased CA2+, rasied phosphate , K+ and renin
- U&Es
- Urine and blood cultures - UTI,
- Urine dip stick - haemtouria and protinaureia suggetss glomerular necrosis
- Albumin ot creatine ration, protien to creating ration
- Renal ultrasoud for obstruction
- Serum biochemistry- U&Es, creatine, bicarbonate
CT - usefu for diagnosis of retroperitoneal fibrosis and urinary obstruction
chronic kidney disease treatment
- Treat underlying causes - antibiotics, immunosurpressant for vasculitis, metabolic controll in diabetties, stop nephrotoxic drugs, IV fluid for volume depletion, manage blood pressure,
- Statins
- Lifestyle - less sodium and potassiom, vitamin d supplement
- Stop nephrotoxic drugs
- Treat hyperkalaemia
- Dialysis
Kindney transplant
chronic kidney disease complications
Hyperkalaemia
Vit d deficancy
Hypertension
Pericarditis
Aneamia
Metabolic acidosis
Oseeoporosis
UTI definition
The inflammatory response of the urothelium to bacterial invasion with bacteriuria and pyuria. It is the growth of >10^5 organism/ml of fresh mid-stream urine
UTI epidemiology
Women - 20% will have one in their lifetime
Elderly patients
Hospitalized patients
Renal transplant
UTI causes
Gram negative
* E Coli (most common)
* Proteus mirablis - renal stones
* Klemsiella pneumonia - hospital catheters
* Pseudomonas aerginosa - underlying pathology
Gram positive:
* Staph saprophyticus - lactose fermenting, catalase positive, coagulase negative - 2nd most common, the sex one for females
* Enterococcus
TB
Catheterisation - incomplete voiding and urine statists
UTI risk factors
Female
Sex! No surely not!
Menopause
Catheterisation
Pregnancy n
Diabetes
Urinar tract obstructions
Malformations
Immunosurpression
Asymptomatic - over 65s
Uncomplicated - non pregnant females
Complicated - children, pregnant females, immunocompramised, urosepsis, cataterised patients
UTI pathophysiology
Urine is sterile but bacerial which livs normally fine can move up. Often bowl flora.
Lower UTIs are notammly due to an ascending infection - cystitis, urethritis, prostatitis
Epidydimal orchitis is where the testicles and epidimus become swollen and painful due to an infection
UTI signs
Pyuria
lower - incontanence, pain on peeinf
Upper - fever and haematuria
UTI symptoms
Upper UTI – systemic symptoms
Loin/abdominal pain
Tenderness
Nausea
Vomiting
Fever
Costovertebral angle pain
Lower UTI – HD FUSS
Hematuria
Dysuria
Frequency
Urgency
Suprapubic pain
Smelly urine
UTI tests
- Urine dipstick - blood, proteins, nitrites leukocytes, pH, glucose, ketones
- Midstream sample - voids the bacteria and get it fresh
- Supra pubic aspirate
- Early morning urine - look for TB that has accumulated in the urine
Microscopy - WBC increase, RBC, bacteria, epithelial cells, cultures
UTI treatment
- If its asymptomatic, then don’t treat
- Uncomplicated - non pregnant females - give 3 days of antibiotics, increased fluid intake, void post intercourse and improve hygine
- Complicated - always send culture, 7 day antibiotic course, nitrofurantoin should be avoided in pregnancy and has side effects of N&V, liver problems and weakness.
- New antibiotics are reserved for the resistant infection- fosfomycin, pivemcillin
1st line - nitrofurantoin (1st trimester preganys only!) trimethoprim (3rd trimester pregnancy only!) or cefalexin
2nd line - ciprofloxacin or co amoxiclav
To prevent, drink fluids, urinate after sex and have good hygine.
pyelonephritis definition
Infection of the parenchymal soft tissue of the renal pelvis and upper ureter
pyelonephritis UTI epidemiology
Females under over 35
Significant sepsis and system upset
pyelonephritis causes
KEEP
Klebsiella
Enterobacter
E coli - most common
Proteus
pyelonephritis risk factorss
Structural renal abnormalities -which causes vesicoureteral reflux
Catheterisation
Pregnancy
Diabetes
Immunosuppression
Calcuili
pyelonephritis pathophysiology
Infection is normally from bacteria from the aptines own bowel
It can be ascending, or come from eh blood stream or lymphatics
Haematogenous - aureus , candida
Lymphatic - rare
pyelonephritis signs and symptoms
Usually unilateral
Triad of loin/flank pain, fever, pyuria
N&V
Costovertebral angle pain
Rigors (chills)
pyelonephritis tests
Urine dipstick - nitites, bacterial breakdown produced nities
WBC
Foul smelling urine
Abdominal investigation - tender loin, renal angle tenderness, vag exm -rule out pathology there
Bloods- wBC ESR nd CRP may all be raised
Ultraous to tule out obstruction
Gold standard: MSU with microscopy, culture and sensitivity!
pyelonephritis differential
Diverticulitis
Abdomial aortic anyerism
Kisdey stones cystitis
Proastatitis
pyelonephritis treatments
Hydration - fluid repkacement
IV antibiotoc - brad spectrum - co amoxilav and gentamicin
If pregnancy use cefalexin
Drai the obstructed kidney
Cathater
Analgesia
7-14 das of antibiotics
pyelonephritis complications
Renal absess - no respnse to antibiotics, imaging sows then
Emphsematous pyeloneophritis - gas accumulationin liddues, life threataning, may need nephrectom
cystitis definition, epedemiology and bacterial causes
Urinary infection of the bladder
Females
E coli
cystitis risk factros
Urinary stasis
Bladder stones
Poor emptying
cystitis key presintations
HD FUSS
* Haematuria * Dysuria * Frequency * Urgency * Suprapubic pain * Smelly urine Loin tenderness
cystitis key presintaiotiosn
HD FUSS
* Haematuria * Dysuria * Frequency * Urgency * Suprapubic pain * Smelly urine Loin tenderness
cystitis first line test
Microscopy and sensitivoty of MSU - gold standard
Urine dipstick - positive for leuokocytes, blood and nitrates
cystitis treatment
1st line - nitrofurantoin (1st trimester pregant only ) trimethoprim (3rd trimester only) or cefalexin
2nd line - ciprofloxacin or co amoxiclav
prostatitis definition
Infection of the prostate gland
prostatitis causes
- Acute prostatis - strep faecalis, Ecoli, Chlamydia
Chornic- strep, faecalis, ecohil or chlamydia, elevated prosteate pressure, pelvic floor myalgia
prostatitis risk factors
Sti
Uti
Indwellign cathater
Post biopsy
Increasing age
prostatitis key presintations
Systemically unwell
Fever
Malaise
Rigirs
Painful ejaculating
Pelvic pain
Voiding LUTS - streaming poor stream, incomplete emptying, hesitancy, dysuria.
prostatitis tests
DRE - prostate is tender and hard from calcification
Blood cultrues
MSU
STI screen
Urine dipstick - posituve or leucoctes and nitries
Trans ureteral ultrasoud
prostatitis differential
Cystitis
BPH
Calculi
Prostatic abcess
Malignancy
prostatitis treatmetn
- Acute - gentimicin and co-amoxiclav
- Second line trumethroprim
Chronic - 4-6 week course of quinooone, ciprofloxacin - alpha blocker - tamsulosin
urethritis definition
Uretheral inflamation
Urethritis epidemiology
Diagnosed in men at SH clinics
Non conoccocal urethritis is more common
Urethritis cases
- Neisseria gonorrhoea
- Chlamydia - most common
Mycoplasma genitalium - Trichomonas vaginalis
- Non-infective:
Trauma
Urethral stricture
Irritation
Urinary calculi (stones)
Urethritis risk factors
Unprotected sex
Male to male sex
Urethritis key presintations
- Asymtomatic
- Sysutia
- Discharge and pain
- Uretheral pain
- Penile discomfort
- Skin lesions
Systemic symptoms
Urethritis test
- Nucleic acid amplification test
- Microscopy of gram stainesd smears fo fenital secretions
- Blood cultures
- Urine dipstic
Uretheral smear
Urethritis differential
Candida balanitis
Epididymitis
Cystitis
Acute prostatitis
Urethral malignancy
Urethritis treatment
- Chlamydia
○ Oral azithromycin or 1-week oral doxycycline
○ Pregnant – oral erythromycin (14 days) or oral azithromycin - Gonorrhoea
○ IM ceftriaxone with oral azithromycin
○ Partner notification - Patient education
Contact tracing
Epidydimo- orichitis definition
Swellling of the epidydimus that can spread to the testes
Epidydimo- orichitis causes
STI - chlamydia and gonorrhoea
Utis - klebsiella, ecoli enttterococcus, pseudomonias, staphylococcus
Mumps
Trauma
Elderly
Epidydimo- orichitis risk factors
Previous infections
Indwelling catheter
Abrnormality f the urinary tract
Anal intercourse
Epidydimo- orichitis key presintations
- Scrotal pain and swelling
- Urethritis
- Uretheral discharge
- Mumps - eadach and fever
- Tenderness
Sweats/fever
Epidydimo- orichitis test
- Nucelic acid amplification test
- MSU dipstick
- Ultrasound to rule out abcess
- Blood cultrues
- STI screening
Iretheral smear and swab
Epidydimo- orichitis differntial
Testicular torsion
Hydrocele
Trauma
Abcess
Epidydimo- orichitis treatmetn
- Chlamydia
○ Oral azithromycin or 1 week oral doxycycline
○ Pregnant – oral erythromycin (14 days) or oral azithromycin - Gonorrhoea
○ IM ceftriaxone with oral azithromycin
○ Partner notification - UTI
○ Oral ciprofloxacin - Analgesia – NSAIDs e.g. ibuprofen
- Partner notification and testing
Abstinence
define nephrtic and nephrotic syndrome
- Nephritic syndrome means that there is a round of symptoms - haematuria, oliguria, proteinuria, fluid retention
Nephrotic syndrome means that the person has a goup of symptos which are oedema, protinuria low serum albumin and hypercholesterolaemia
define glomerulonephritis
- Glomerulonephritis - inflammation of the glomeruli and nephrons the consequences of which are:
* Restricted blood flow leading to increased BP
* Damage to filtration mechanism to blood and protein enter urine
* Loss of filtration capacity leading to acute kidney injury
what is used to see if there is bleeding in teh kidnyes
red blood cast cells in teh urine!
Nephrotic syndome key presintations
- Periphreal oedema
- Protinuria more >3g/24 hours
- Serum albumin less than 25g/l
Hypercholesterolaemia
Nephrotic syndome additional symptoms
- Frothy urine
- High cholesterol
Hypercoagulabilityleading to increased wirk of thrombus
Nephrotic syndome treatment
- Immunsurpression with sterioid (predinisilone)
- Blood pressure bontroll with ACEi or ARB
- Diuretics for oedema
Water and salt restrictinos in diet
Nephrotic syndome types
- Minimal change disease - most common in children, treated with sterioids, its idiopathic
- Focal segmental glomerulosclarosis - most common in adults
- Membranous glomerulonephritis - most common glomerulonephritis overall, IgG and complement depositis in the basement membrane. Idiopathic causes, can be secaondary to malinnancy, rhumatoid diseases, drugs, Hep B&C and NSAIDs
Nephritic syndome key presintations
- Haematuria
- Oliguria
- Proteinuria
Fluid retention (oedema)
Nephritic syndome treat,ent
- Immunsurpression with sterioid (predinisilone)
- Blood pressure bontroll with ACEi or ARB
- Diuretics for oedema
Water and salt restrictinos in diet
Nephritic syndome types
- IgA nephropathy - the mos cmoon causes of primary, peak age is 20, histology shows IgA depositis and glomerular mesangial proliferation (bergesrs disease)
- post streptococcla glomerulonehritis (diffuse proliferative glomerulonephritis) - paitint under 30, 1-3 weeks after strep pyogenes infection (URTI), usually a full recovery.
Goodpasture’s syndrome - anti GBM antibodies attack the glomerulus and pulmonary basement membranes causing glomerulonephritis and pulmonary haemorrhage - patients present with acute kidney failure and haemoptysis
diiffuse proliferaev glomerulonehritis definition, epidemiology, pathophysiology tests and treatmenr
Diffuse proliferative glomerulonephritis
The most common form of lupus nephritis
More common in females
And between 15-45 age
Autoimmune condition from lupus - this is when it’s at stage 4 of the progression
Renal biopsy -
Prednisolone
membranoproliferative glomerulonephritis definition, tests and treatment
Autoimmune disease - lupus, sarcoidosis,, Sjogren, cancer (leukaemia, lymphoma) Hep B&C, endocarditis, malaria. It is caused by kidney deposits in the membrane and mesangium.
Not to be confused with membranous glomerulonephritis which is just lupus formed and affects the BM only
Renal biopsy
Prednisolone
Nephrotic syndome calssic triad ofkey presintations
There is a classic triad of:
* Low serum albumin
* High urine protein
Oedema
Nephrotic syndome signs and symptoms
Oedema
Xanthalsma
Xanthoma
Leukonychia
Shortness of breat
- Peripheral oedema
- Facial oedema
- Frothiness of rine
- Fatigue
- Poor appetite
- Reoccurent infections
Venous/arterial thrombosis due t hypercoagulabilit
Nephrotic syndome tests
Urine dipstick - high protein
Frothy appearance
Nephrotic syndome treatmetn
- Loops diuretic for oedema
- Ace inhibitors to reduce proinurina
- Statins to reduce cholesterol
Anticoagulants if necessary treat the underlying causes - stop causative drugs etc
Nephrotic syndome complications
- Higher risk of thromboembolism due to hypercoagulability
Hyperlipidaemia - bad for strokes and MI
minimal change disease definiftion
Nephrotic syndrome occurs in isolation without any clear underlying conditions
what is teh most common causes of nephrotic syndrome in children
minimal change disease
minimal change disease tests
Renal biopsy and microspecies will not show any abnormalities, urinalysis will show small molecular weight proteins and hyaline casts
minimal change disease treatmetn
- Prednisolone or other corticosteroids very effective but there can be remission
- Restricted fluid and salt diet
- Albumin infusion
- IV furosemide - diuretic to reduce oedema, given IV due to bad absorption because of oedema in stomach
Focal segmental glomerulosclerosis definition
Focal segmental glomerulosclerosis (FSGS) is a chronic pathological process caused by injury to podocytes in the renal glomeruli. It manifests initially with proteinuria, which progresses to nephrotic syndrome and ultimately to end-stage renal failure
Focal segmental glomerulosclerosis causes
There can be secondary causes - sickle cell diseases, HIV, renal hyperfiltration, heroin abuse
Genetic aspect
Focal segmental glomerulosclerosis risk factors
Male
Black
Family history
Heroin abus
Focal segmental glomerulosclerosis pathophysiology
- Foot process of podocytes damaged leading to plasma proteins and lipids periating the glomerular filter
Protein and lipids then get trapped and leads to glomerulosclerosis
Focal segmental glomerulosclerosis test
- Protein in urine >3.5g/l
Kidney biopsy most definitive too looks for damage to podocytes
Focal segmental glomerulosclerosis treatment
- Treat cause - for example weight loss can help, antiviral therapy for HIV, heroin detoxification
- Ace inhibitor or angiotensin ii receptor agonist if ace not tolerated and sodium restriction
- Consider stattin
- Furosamide and thazide diuretic for oedema
Immunosuppressants - prednisolone
Membranous nephropathy definition
Inflammation of the glomerular basement membrane caused by immune complex deposits.
Membranous nephropathy epidemiology
One of the most common causes of nephrotic syndrome in adults
Membranous nephropathy causes
- mainly idiopathic
Secondary:
* Infections - hep B &C, syphyliss
* NSAIDS, pencillamine
* Systemic lupus ertheamatous
Malignancy
Membranous nephropathy risk factors
- Male
- Over 40n
- Autoimmune disease
Membranous nephropathy pathophysiology
- Autoantibodies target the glomerular basement membrane
- Complexes build up which causes damage to podocytes and mesangial cells
- There is a recruitment of inflammatory cells which lead to damage and protein leakage
A diagnosis of primary MN should only be made after secondary causes have been excluded
Membranous nephropathy pathophysiology
- Autoantibodies target the glomerular basement membrane
- Complexes build up which causes damage to podocytes and mesangial cells
- There is a recruitment of inflammatory cells which lead to damage and protein leakage
A diagnosis of primary MN should only be made after secondary causes have been excluded
Membranous nephropathy test
- Urinanalysis
- Urine protien to creatine ration
- Serum urea
- Serum creatine
- Biopsy - thiekcening of glomerular membrane
Looks for hepatitis
Membranous nephropathy treatment
- Low protien and salt diet
- Ace inhibitors if hypotensive
- Statins if hyperlipidaemia
- Furosemide if oedema
- Treat the underlying causes
If there is high ris pf serious kidney injusry give corticosteroids
nephritic syndrome definition
Haematuria, mild to moderate proteinuria, hypertension, oliguria and red cell casts in the urine.
nephritic syndrome key presintations
- Anaemia due to blood loss
- Oedema dur to hypoalbinuria
Hypertension to compensate
IgA nephropathy definition
IgA depositis in the mesangium which leads to the kidye being attack ed by anti-glycan autoantibodies
IgA nephropathy key preintations
- Usually in childhhod or during GI or resp infections
- Haematuria
- Proteinuria
- Hypertensin
- Oedema
- Oliguria
- Uraemia
- Decrease in GFR
Henoch-Schonlein Purpura (HSP)
IgA nephropathy test
Urine analysis - erythrocytosis and proteinuria
gold standard: Kidney biopsy - immunofluorescence shows diffuse mesangial proliferation and extracellular matrix expansion
IgA nephropathy treatment
- Observation
- ACE in inhibitors for hypertension
- Smoking cessation, low salt diet, weight control, exercise
If more extreme corticosteroid - prednisolone
Post strep glomerulonephritis definition and pathophysiology
- Caused by type 3 hypersensitivity
Immune delayed consequence of pharyngitis or skin infections caused by streptcoccus pyogenous or beta haemolysitc group A strep
IgG is deposited in the basement membranes which causes an inflammatory reaction in the glomerulus and deposit of inflammatory cytokines, oxidants and proteases that damage the podocytes
Post strep glomerulonephritis epidemiology
- Children
1-2 weeks are upper resp tract infection
Post strep glomerulonephritis key presintations
- There will have been a recent infection
More common in people under 30
Post strep glomerulonephritis test
- Kidney biopsy will show glomeruli are hypercellular
On immunoflorescent tehr are IgG and IgM depositis
Post strep glomerulonephritis treatment
Furosomide for hypertension
Antibiotics
Usually they make a full recovery
goodpastures syndreom definition
Type 2 hypersensitivity reaction - Autoimmune condition where there are anti-GBM autoantibodies which attack the
Maly affects the lungs and the kidneys causeing heamoptysis and haemureia
Collagen 4 is the most common in these organs BM, igG antibpdies bind to the collagen chain and activate the complement system, this si a hypersensitivity type 2 reaction
Lung symptoms normally come first
goodpastures syndrome causes
nfection
Smoking
Oxidative stress
goodpastures syndrome key presintations
- Haematuria and heamoptyisis
Cough, SOB, nausea, lung crackles
if there is blood in the quatar and blood in teh urin, think goodpastrues!!!!!`
goodpastures syndrome testing
- Renal function testing
Biopsy- inflammation of BM
Immunofluorescence - shows prescenc of IgG antibodies
goodpastures syndrome treatment
- Oral corticosteroid - high does of prednisilone
- Prophylactive measures for taking hight levles foo steroids
If treat eed early prognosis is good, they might however need dalysis as it can lead to renal faliure
SLE nephropathydefinition
nflamation of the kidney due to systemic lupus erythematous. This is causede by antinucleur antibodies whiuc bind to nucler antigens forming antigen-antibody complexes leadsing to deposits and type 3 hypersensitivity reactions
SLE nephropathy pathophysiology
- There are different classes depending on severity
There can be complication such as thrombosis and embolism
SLE nephropathy key presintations
Rash, arthralgia, pericarditis, pneumonitis
SLE nephropathy tests
Low complement factros C3 and C4
biopsy
SLE nephropathy treatments
mmunosurpressants - prednisilone
vasculitis nephropathy definition
A systemic illness characterised by the inflaation of blood vessles, the blood vessles occulsion and sebsequent isceamin in the organs and tissues
benign prostate hyperplasia definition
Proloferation o the musculofiberous glandular tissue of the inner zone of the prostate
benign prostate hyperplasia epidemiology
- Men <60
- Incrases in epithelial and stomal cells in the periuretheral area of the prostate
- Affects afro carribean ethnicitues more than white men
benign prostate hyperplasia risk factors
Risk Factors
Age
Castration is protective
Family history
benign prostate hyperplasia pathophysiology
Pathophysiology
- PSA prostate specific antigen - serine protease responsivle fr liquification of semsn, there is a small amount of leakadge, it is elevated in UTIs, BPE and prostatitis or CANCER
- Benign proliferation of the transitional zone, the peripheral layer expansion is prostate cancer normally
- Men produce less testosterone and more dihydrotestosterone which causes hypertrophy from the prostate cells
- The prostate will then block the bladder causing dilation, urine statis and UTIs
benign prostate hyperplasia key preintations
Key presentations
Storage -
* Frequency increases
* Urgancy
* Nuctura
* Urgancy incontinence
Voiding - SHIPP
* Straining * Hesitancy * Incomplete ememptying * Poor intermittant stream * Post micuration dribiling
benign prostate hyperplasia signs
Signs
Bladder stones
Urinary retention
UTIs
Haemataure, painful urination are red flags
Painless haematuria is cancer until proven otherwise!!!
benign prostate hyperplasia tests
1st line test
- Internation prostate symptom score
- Digital prostate exam
- Urine dipstick
- Tran rectal ultrasound
- Biopsy
- Abdominal exam
- U&E and renal ulatrason
- PSA - may be raised
benign prostate hyperplasia differential
Differential diagnosis
Overracive blader syndrome
Bladder tumour
Bladder stonesj
Trauam
UIT
Prostatitis
Biopsy
Bladder/ prostate cancer
benign prostate hyperplasia treatment
Treatment
- Avoid caffeine and alcohol
- 1st line - selective 1- adrenergic receptor antagonist - oral tamsulosin or alfuzosin- relaxes the smooth muscle of the bladders increase urinary flow rate - risk of postural hypotension so should be taken at night
- 2nd - 5-a-reductase inhibitors - finasteride, dutasteride, inhibit conversion of testosterone to ore active dihydrotestosterone
- Catheterisation
- Bladder training
- Surgical treatment - transurethral resection of the prostate is the gold standard
- Bladder neck incision
- Trans ureteral incision of prostate
benign prostate hyperplasia complications
Complications
Bladder calculi
UTI
Haematuria
Acute retention
prostate cancer pathophysiology
Normally are adenocarcinomas arising in the periperal zone - 67% of men over 80 have prostate cancer
- Adenocarcimoas - most common
- Transitional cell carcinoas = arise form the transitional zone
- Small cell prostate cancer - neuroendocrine cells
- Hey may spread through semial vesivles, bladder and rectum, lymph nodes, to bone brain, liver and lung
- Can metastatise to bone, lung and adjacent issues
PSA can be done for screeing but itsnt very reliable, 70% of raised PSAs arent cancer
prostate cancer risk factros
Old age
Obesity
Family history
High fat low fibre diet
Black skin
High testosterone
prostate cancer symptoms
- Asymptomatic to stat
- LUTS symptoms the same as BPH - nocturia, hesitancy, poor stream, post micuration dibilling, obstruction, haematuria,
- B syptoms - weight loss, loss og apetite, night sweats, anaemia
Bone pain - metastasis
prostate cancer tests
PSA raised
biopsy and gradingusing teh gleason score
imagign
scan for mets
prostate cancer differentials
BPH
Prostatitis
Bladder tumour
prostate cancer treatment
- Watchful waiting
- Radical prostatectomy
- Radical radiotherapy
- Hormone therapy - to slow the growth, GnRH agonists, androgen recepotr blockers
- Metastatic - bilateral orichodectom
- Palliative care
- Treat hypercalcaemia
Bisphosphonate
testicular cancer epidemiology and risk factros
14-44 age
10% of undescended testis
96% arise form germ cells
Undescended testis
Family history
testicular cancer signs and symptoms
Hydrocele
Testicular mass
Lump on testical
Testicularpain
Abdo pain
Haematospermia
Cough and dysponea
Back pain
testicular cancer tests
Ultrasound of testes is the best!!!
Biopsy and histology - seminoma - fried egg like
Serum tumour markers - alpha fetoprotine and beta subunit of human chorionic gonadotrophin, lactate dehydrogenase
CXR and CT to asses tumour staging
testicular cancer differentials
Testicular torsion
Lymphoma
Hydrocele
Epidydimal cyst
testicular cancer treatment
Radical orchidectomy via inguinal approach to reduce seeding of the tumours
Radiotherapy - seminomas with metastases
Chemotherapy – more widespread tumours and teratomas
Sperm storage
kidney cancer epidemiology
Renal cell carcinoma
55 age
#male more than female
Most are picked up accidently
kidney cancer risk factros
Family history
Smoking
Obesity
Hypertension
CKD
Renal abnormalaties
Reanl faliure and haemodialysis
kidney cancers signs and symptoms
Abdominal mass
Obstruction
Loin flank pain
Haematuria
Abdominal mass
These are eth classic triad!!
B symptoms - night sweats weight loss, loss of appetite
Fever
Anaemia - EPO linked
kisney cancer tests
Ultrasoun - benign cyst vs complex cyst vs tuour
CT scan - more sensitice ad will show renal involvemebt
MRI
Blood - FBC, U&Em Calcium
Urinanalysis
Biopsy
Bone scan
kidney cancer differential
Transitional cell carcinoma
Wilms tuour
Renal onocytoma
Leiomyosarcoma
kidney cancer treatment
- It is resistant to traditional chemo and RT
- Ablation/cryotherapy can be done if the tumour is smaller than 4cm or in pallative settings
- Localised - radical nephrectomy and lymphonodectomy (taking out the whole kidney and the lymph nodes)
- Partial nephrectomy (only the tumour is removed) if there is bilateral involvement
- Radiotherapy
- Metastatic – biological therapies
○ Interluekin-2 and interferon alpha
○ mTOR inhibitors - temsirolimus
○ Tyrosine Kinase inhibitors - sunitinib, sorafenib
Monoclonal antibodies – bevacizumab
kidney cancer compliccations
Paraneoplastic syndromes – production of hormones
EPO – more RBCs 🡪 polycythaemia
PTHrP – hypercalcaemia
ACTH – more cortisol 🡪 Cushing’s
bladder cancer risk factors
Smoking - main one
Paraplegia
Occupational expose to carcinogens - aromatic amines, rubber industry, beta naphthylamine, benzidine and azo dyes
Exposure to drugs e.g. phenacetin and cyclophosphamide
Chronic inflammation of urinary tracts e.g. schistosomiasis (usually associated with squamous carcinoma), bladder stones or indwelling catheters
bladder cancer pathophysiiology
Tumour spread - localy to pelvic structures
Lympthaitc - to illiac and paraaortic nodes
Haematogenous
90% urothelial transitional cell carcinaomas!!
Squamous cell carcinoma - UTI and kidney sones
Adenocarcinomas - frequently metastasis
bladder cancer key presintations
Painless haematuria - think bladder cancer!!!!! (1/5 have a malignancy)
Reoccur ant UTIs or UTI like symptoms - frequency urgency, dysuria but absence if bacteria
LUTS -
Mucusuria
Abdominal mass
B symptoms - weight loss, night sweats, loss of appetite
Voiding irritability
bladder cancer tests
Cystoscopy and biopsy - diagnostic
Urine dipstick
Urine microscopy
Urinary tumour markers
CT/MRI of pelvis
CT urogram – provides staging and is diagnostic
bladder cancer differntial
Haemorragic cystitis
Renal cancer
UTI
Uretheral trauam
bladder cancer treatmetn
- Non-muscle invading bladder cancer (Ta or T1)
○ Transurethral resection of bladder tumour (TURBT)
§ Specimen must include muscle to stage
○ Mitomycin C
○ BCG - Muscle invasion
○ Radical cystectomy and conduit/neobladder
○ Radical radiotherapy ± chemotherapy - Transuretheral resectino of blader - both diagnostic and can be a tratment
- Intravestical therapy - mitomycin - reduced reoccuranc eof bladder cancer, it is put inot the bladder, left for an hour and then removed. This is an antibiotic but it very cytotoxic.
- Radical cystoprostectomy - removal of prostate and bladder
Anterior exteneration - removal pf bladder, urethram ureters, uterus and vagina.
Polycystic kidney disease definition
Genetic disorder where the kidney becomes surrounded by flid
Multiple cysts gradullay grow and cuases renal enlargement, kidney destruction and reanl faliure
Polycystic kidney disease causes
Simple - develop over time
Aquires - ckd
Genetic
Syndromic diseases - Tuberous sclarosis
Drugs - lithium
Polycystic kidney disease cyst types
Difference tyoes
* Simple - benign
* Polycystic - mustiple
* Dysplasia - not formed correctly
* Medullary sponge - dilation of collecting ducts
* Acquired cystic disease
Polycystic kidney disease pathophysiilogy
- If genetic there is a predisposition to cyst formation
Increased abnormal cell hyperproliferation 🡪 loss of planar polarity 🡪 cyst initiation
Autosomal dominant PKD cause
- Mutation on PKD1 gene on chromosom 15 - more severe and earlier onset
Mutaiton on PKD” on chromoxome 4 - less severe and later noset
Autosomal dominant PKD pathophysiology
- PKD1 encodes polycystin 1 which is involved in cell-cell and/or cell-matrix interactions – regulates tubular and vascular development in kidneys
- PKD2 encodes polycystic 2 which functions as a calcium ion channel
Disruption results in reduced cytoplasmic Ca2+ causes disorientated cell division and cyst formation
Autosomal dominant PKD signs
- Hypertension
- UTI and pyelonephritis
- Renal failure
- Sub arachnoid haemorrhage
Liver cysts
Autosomal dominant PKD symptoms
- Loin pain
- UTI
- Abdominal dicomfort
- Noturia
- Heamaturia
Renal colit due to clots
Autosomal dominant PKD tests
Genetic testing for PKD1 and PKD2
Ultrasound – diagnostic if:
With Fx - <30 at least 2 cysts
15-39 years > 3 cysts (uni/bilateral)
40-59 years > 2 cysts (each kidney)
> 60 years > 4 cysts (each kidney)
Autosomal dominant PKD differential
- Aquired cysts
- Autosoma recessive
Tuberous sclaros
Autosomal dominant PKD treatmetn
- Blood pressure controll
- Laproscopic removal of cysts to help with pain
- Nephrectomy
Renal replaceent therapy
Autosomal recessive PKD epidiemiology and chomosome causes
- More rare
- Disease of infancy - cilhdern born with cysts
PKHD1 mutaiton on chromosom 6
Autosoma lrecessive PKD key presintations
- Infancy renal cysts and congential hepatic fibrosis
- Renal faliure before birth leading to low amniotic fluid and potter sequence
Kidney faliure
Autosomal recessive PKD differential
- ADPKD
- Hydro nephritis
Renal vein thrombosis
autosomal recessive PCKD treatment
- Blood pressure controll
- Laproscopic removal of cysts to help with pain
- Nephrectomy
- Renal replaceent therapy
- Lver transplant
Genetic counselling for family
chlamydia causes
Chlamydia trachomatis - gram negative bacteria
Infect the non sqamous epithelia - urethra, endocervical canal, rectum, pharynx, conjunctiva
In neonates it affects the conjunctiva and sometimes can causes atypical pneumonia
chlamydia key presintations of males and females
MALES:
* Main sight of infection if urethra * Dysuria and ureteral discharge * Asymptomatic * Empdydimo-orichitis and reactive arthritis complications * high transmission to females
FEMALES:
* Main infetion sight is endocerviacl canal * Non speciful symptos - dischage, menstra irragularity, dysuria * Asymtpatic * High transmission * Complications: pelvic inflamatory disease, ectopic preganc, chronic pelvic pain, infertility Neonatal transmissoin
chlamydia firs line tests
Nucleic acid amplification test - high sensitivity and specificity
* First void urine * Endocervicla swab Self-collected vaginal swab
chlamydia treatments
Partner management
Test for other STIs
- Doxycycline 100mg bd for 7 days or azithromycin (1 dose)
- Erythromycin 500mg bd for 14 days OR azithromycin in pregnancy
○ Doxycycline in pregnancy can cause tooth staining
Antibiotic resistance not a clinically important problem
Gonorrhoea causes
Neisseria gonorrhoea - gram negative bacteria
Male more
Infect the non squamous epithelia - urethra, endocervical canal, rectum, pharynx, conjunctiva
Gonorrhoea test
Near person test - microscopy of genital secretion
Looks at the male urethra and female endocervix
Culture on selective medium to confirm diagnosisn
Sensitivity testing
NAAT
Gonorrhoea treatmetn
Partner notification
Test for other STI’s
Continuous surveillance of antibiotic sensitivity
Single dose treatment preferred
Aim to cure at least 95% of people at first visit
Current regime – Ceftriaxone IM injection with azithromycin
Gonorrhoea symptoms
Symptoms in women
an unusual vaginal discharge, which may be thin or watery and green or yellow in colour
pain or a burning sensation when passing urine
pain or tenderness in the lower abdominal area – this is less common
bleeding between periods, heavier periods and bleeding after sex – this is less common
Symptoms in men
an unusual discharge from the tip of the penis, which may be white, yellow or green
pain or a burning sensation when urinating
inflammation (swelling) of the foreskin
pain or tenderness in the testicles – this is rare
syphellis definition and epidemiology
Treponema pallidum sub species - spiral gram negative bacteria
Early infectious syphilis (within 2 years of infection)
Primary, Secondary and Early Latent
Late syphilis (over 2 years since infection)
Late latent, CNS, gummatous
Male
High risk in male to male intercourse
syphellis stages
- Incubation is 9-90 days
- Musly macule/papule hich is hard clean mased and non tender ulcer
- Primary chancre – 95% genital skin, also nipples, mouth
- ANY GENITAL ULCER IS SYMPHYLIS UNTILL PROVEN OTHERWISE
- Secondary - 6-8 months afer infection there is a rash on limbsm pamls and soles, chest, neck and face. Ther is also malaise, lymphadenopathy , alopecia, bone pain, hepatitis, nephrotic syndrome, deafness, meningitis and hepatosplenomegaly
- ther is then latent stage - an asymptomatic phase
tertiary stage - affects teh nercous system and ther eis granulomatous on skin bone and internal organs
syphellis tests
Near person test - microscopy of genital secretion
Looks at the male urethra and female endocervix
Culture on selective medium to confirm diagnosisn
Sensitivity testing
NAAT
Early moist lesions
Genital ulcers
SEROLOGY- look for antibodies against T pallidum antigens
* there are primary sceeenign tests and then tests done in more detail for those which test postive * Treponema pallidum particle agglutination test (TPPA)
syphyllus treatmetn
- Penicillin IM
Efficant follow up and partner notification
Varocele definition
Abnormla dilation of testicular veins in the pampiform venous plexus cuases by venous reflux
Varocele epidemiology
Left side more commonly affected, incedence increases after pubity,
Associated wth sub fertility
Varocele causes
ncreased reflux form renal vein
Lack of effective vaves between testicular and renal veins
Varocele signs and symtoms
Visable as distended scorla blood vessle that feel like a bag of worms
Sull ache
Scroal heaviness
Varocele test
Venography
Colour duplex ultrasoud
Varocele differential
Secondary to pathalogical process - kidney timous and retroperitona tumours
Varocele treatmetn
surgery is there is pain, infertikity ot testicualr atrophy
hydrocele definition
Abnormal colleciton of fluid within the tunica vaginalis
hydrocele causes
Primary - more common and larger, younger men, patent processus vaginalus
Secondayr - older boys and men, secondary to a tumour, trauma, infection, TB, torsion or general oedema
hydocele pathophysiology
Overproduction oif fluid in the tunica vaginalis
Comunicating - processus vaginalus falied to close allowing peritoneal fluid to communicate freelt with scrotal portion
hydocele signs
Scrotal enlargement with non-tender, smooth cyctic sweli g
Testis is palpable normally
Lies anterior to and below the testis, will transilluminate
hydocele first line test
Scrotal ultrasound
Serum AFP and HCG to look for malignant teratomas or other germ cell tumour
hydocele differential
Testicular torsion
Strangulated hernia
hydocele treatmetn
esolve spontaneously
Many from infancy resolve by 2
Therapeutic aspiration or surgical removal
epidysimal cyst definition
Smooth extratesticular sperical cyst in the head of the epidermis
epidydimal cysts pathophysiology
Clear and milky fluid
Lies benind the testis
epidydimal cyst sins and sytoms
Lump
Translaminar
Testis palpable separately from the cyst
Painful if large
epidydaml cysts test
Scrotal ultrasound
epidydimal cysts differntial
- Spermatocele fluid and sperm filled cyst between epidermis
- Hydrocele
Varicocele
epidydimal cyst treatmtne
Normally left
Surgical excision if painful
testicular torsion definition and epidemiology
Commmon urilogical emergcanc
Most commin in post pubertal boys but can be in all ages
Left side more commonly affected
testicular torions causes
Adlescents and neonated - bell clapper deformitio - - testes is inadaquatly connected to the scrotum which allowsit to move freely on an axis and is more suseptabe to twisting
Adults - malignancy
There is a slight genetic predisposition
testicualr torsion pathohysiology
Twising of the soermatic cord which cuts off blood supply to the testes
Leads to ischeami, infarction and potenital loss of testis
Germ cells are most suseptable to ischeamia
testicular torsion sigs and symptoms
Unilateral pain
High riding testicle
Absent cremasteric reflex
Sudden onset testicular pain - makes walking difficult
Inflamed testicle
Abdo pain
N&V
testicular torsion test
Duplx ultrasoudn
Urinanalysis
testicular torsion differntial
Epididymo- orchitis
Hydrocele
Idiopathic scrotal oedema
testicualr torsion treatmetn
Sugery within 6 hours,
Orchidectomy and bilateral fixation
storage LUTS
Urgency
frequency
Nocturia
Urge incontinence
voiding LUTS
Hesitancy
Intermittency
Straining
Terminal dribbiling
Incomplete emptying
Haematuria
Dysuria
voiding LUT causes
Benign prostatic hyperplasia - most common
Drugs with antimuscaneric effects
Diabetic automonim neuropathy of bladder
Uretheral stricture and phumosis - constricion of the foreskin
Cancer of the prostate, bladder or rectum
storage LUT causes
UTI
Bladder calculi
Urotheleal carcinoma
Overreactive bladder
history questions to ask about LUTS
Fluid intake and urine appearance
volume daily
what they’re drinking (look out for tea, coffee and other caffeine containing drinks)
urinary appearance - colour, frothiness, cloudiness, any changes
timing of fluid consumption - especially late evening
Drugs:
diuretics
herbal formulas
illicit drugs - especially ketamine
antidepressants
Broncho dilators
Antihistamines
Co-morbidities
previous surgery’s
previous trauma
neurological disorders
cardo- resp diseases - heart failure
Diabetes poorly controlled
what is teh most comon causes of UTIS cenraly and teh most common causes of urethritis
UTI - ecoli
urethritis - chlaymidia
what will a urine dipstick test show for UTIs
Urine dipstick test +leukocytes and + nitrites
what does cola coulerd urine mean in kidnye disease
Rhabdomyolysis- dangersou muscle breakdown as a result of kidney disease
what is teh treatment for TB
2 antibiotics (isoniazid and rifampicin) for 6 months.
2 additional antibiotics (pyrazinamide and ethambutol) for the first 2 months of the 6-month treatment period.
what are the risk factors and epidemiology fot IgA nephritic syndrome
16-35
Asain/white/native american
HIV (becuass of reoccurent infections)
what does RIFLE stand for
risk injury, faliure, loss, end stage renal faliure
what is thr risk criteria in rifle
creatinine increased by x1.5
UO <0.5ml/kg/h for 6 hours
what is teh injury criteria in RIFLE
creatinine increased by x2
UO <0.5ml/kg/h for 12 hours
what is the faliure criteria in RIFLE
creatinine increased by x3 (or greater than 4mg/dl)
UO <0.3ml/kg/h for 12 hours
what does the lloss stand for in RIFLE
complete loss f reneal function for longer than 4 weeks
what are some nephrotoxic drugs
antibiotics, NSIADS, Ace inhibitors
