Urogenital and renal Flashcards
Give 3 symptoms of testicular torsion
- ) Sudden onset of pain in one testis (walking uncomfortable)
- ) Abdominal pain
- ) Nausea
- ) Vomiting
Give 2 signs of testicular torsion
- ) Inflammation of one tests - tender, hot, swollen
- ) Testis may lay high and transversely
Between what ages is testicular torsion more common?
11-30
What is the main differential diagnoses of testicular torsion?
Epididymo-orchitis
What do we do to diagnose testicular torsion?
Doppler US may demonstrate lack of blood flow to testes
What is our immediate thought when someone presents with a suspected testicular torsion?
Immediate surgery
What is the treatment for testicular torsion?
Possible orchidectomy and bilateral fixation - expose and untwist, fix to scrotum
What is a hydrocele?
Fluid within the tunica vaginalis
What is primary hydrocele associated with?
Processus vaginalis (typically resolves in 1st year)
Give 2 causes of a secondary hydrocele
- ) Tumour
- ) Trauma
- ) Infection
Which type of hydrocele is more common and larger?
Primary
How do we treat hydroceles?
Aspiration or surgery
What is a varicocele?
Dilated veins of the pam-uniform plexus
Which side is more commonly affected by varicoceles?
Left
What do varicoceles present as?
Often visible as distended scrotal blood vessels that feel like ‘a bag of worm’s, possible dull ache
What are varicoceles associated with?
Subfertility
How do we repair varicoceles?
Surgery or embolisation
What are epididymal cysts?
Contain clear/milky (spermatocele) fluid
When do epididymal cysts usually develop?
Adulthood
Where do epididymal cysts usually occur?
Above and behind testes
How do we treat symptomatic epididymal cysts?
Remove
What is epididymo-orchitis?
Inflammation of the epididymis and testes
What is epididymitis?
Inflammation of the epididymis
Give 3 causes of epididymo-orchitis
- ) Chlamydia
- ) E. coli
- ) Mumps
- ) N. gonorrhoea
- ) TB
Give 3 symptoms of epididymo-orchitis
- ) Sudden-onset tender swelling
- ) Dysuria
- ) Sweats/fever
- ) UTI/STI symptoms
How do we treat epididymo-orchitis? (4)
- ) Antibiotics
- ) Analgesia
- ) Scrotal support
- ) Drainage of any abscess
What antibiotics do we give in epididymo-orchitis? (3)
- ) <35 doxycycline
- ) Ceftriaxone if gonorrhoea
- ) >35 (non STI) ciprofloxacin/ofloxacin
How may the organism infect in epididymo-orchitis?
- ) Retrograde spread from prostatic urethra and seminal vesicles
- ) Bloodstream (less common)
How do we diagnose epididymis-orchitis?
MSU and STI screen
If we cannot get above a scrotal mass, what is it?
Inguinoscrotal hernia or hydrocele extending proximally
If a scrotal mass is separate and cystic, what is it?
Epididymal cyst
If a scrotal mass is separate and solid, what is it?
Epididymitis/varicocele
If a scrotal mass is testicular and cystic, what is it?
Hydrocele
If a scrotal mass is testicular and solid, what is it?
Tumour, haematocele, granuloma, orchitis, gumma
What is a haematocele?
Blood in tunica vaginalis
What does a haematocele follow?
Trauma
How do we treat a haematocele?
Drainage/excision
What is the pathology of benign prostatic hyperplasia? (BPH)
- ) Benign nodular or diffuse proliferation of musculofibrous and glandular layers of the prostate
- ) Inner (transitional) zone enlarges (in contrast to peripheral layer expansion in carcinoma)
Give 4 symptoms of BPH
LUTS
- ) Nocturia
- ) Frequency
- ) Urgency
- ) Post-micturition dribbling
- ) Poor stream/flow
- ) Hesitancy
- ) Overflow incontinence
- ) Haematuria
- ) Bladder stones
- ) UTI
How do we test for BPH?
- ) PR exam
- ) MSU
- ) U&E
- ) US
- ) PSA
- ) Biopsy
What are the treatments for BPH? (3
0-) Lifestyle (caffeine, alcohol, voiding techniques, train bladder)
- ) Drugs (alpha-blockers tamsulosin; 5-alpha-reductase inhibitors, finasteride)
- ) Surgery
How do alpha-blockers work in the treatment of BPH?
Decrease smooth muscle tone of prostate and bladder
How do 5-alpha-reductase inhibitors work in the treatment of BPH?
Reduce conversion of testosterone to the more potent androgen dehydrogenase
What should patients use when using 5-alpha-reductase inhibitors?
Condoms - excreted in semen
What are our surgical options for BPH?
- ) Transurethral resection of prostate (TURP)
- ) Transurethral incision of prostate (TUIP)
- ) Retropubic prostatectomy
- ) Transurethral laser induced prostatectomy (TULIP)
What is the major cause of incontinence in men?
Enlargement of the prostate
What surgery in men may cause incontinence?
TURP
What is functional incontinence?
Too slow in finding the toilet due to immobility or unfamiliar surroundings
What is stress incontinence?
Leakage from an incompetent sphincter (e.g in coughing, laughing, pregnancy, after birth)
Give 2 risk factors for stress incontinence
- ) Age
- ) Obesity
How do we test for stress incontinence?
- ) Loss of small frequent amounts of urine when coughing etc
- ) Examine for pelvic floor weakness/prolapse/pelvic masses
- ) Cough leak on standing with full bladder
What is urge incontinence/overactive bladder?
The urge to urinate quickly followed by uncontrollable and sometimes complete emptying of the bladder as the detrusor muscle contracts
Give 3 things that can precipitate urgency/leaking
- ) Arriving home
- ) Cold
- ) Sound of running water
- ) Caffeine
- ) Obesity
What is the cause for urge incontinence/overactive bladder?
Detrusor overactivity
Give 3 treatments for detrusor overactivity
- ) Antimuscarinics
- ) Topical oestrogens
- ) Beta 3 adrenergic agonist
- ) Intravesical botulinum toxin
- ) Surgery
- ) Bladder training
Give 2 other causes for urge incontinence/overactive bladder
- ) Urinary infection
- ) Diabetes
- ) Diuretics
- ) Atrophic vaginitis
- ) Urethritis
What is continuous incontinence due to?
Due to fistula (between vagina and bladder)
In who does social incontinence occur?
Dementia, confusion, sedation
How do we treat stress incontinence?
- ) Pelvic floor exercises
- ) Intravaginal electrical stimulation
- ) Surgery
- ) Duloxetine
How do we treat urge incontinence?
- ) Examine for spinal cord and CNS signs, vaginitis
- ) Bladder training
- ) Weight loss
- ) Aids, absorbant pads
How can we treat vaginitis?
Topical oestrogen therapy
What is bacteriuria?
Bacteria in the urine (symptomatic/asymptomatic)
Give 2 lower UTIs
- ) Cystitis (bladder)
- ) Prostatitis (prostate)
Give an upper UTI
Pyelonephritis (kidney/renal pelvis)
What is bacterial cystitis/urethral syndrome?
A diagnosis of exclusion in patients with dysuria and frequency
What is the classification of a UTI? (2)
Complicated - structural/functional abnormality of the GU tract (obstruction, catheter, stones etc)
Uncomplicated - normal renal tract structure and function
Give 3 risk factors for developing a UTI
- ) Increased bacterial inoculation
- ) Increased binding of uropathogenic bacteria (spermicide use, decrease oedstrogen, menopause)
- ) Decreased urine flow
- ) Increased bacterial growth
Give 2 causes for bacterial inoculation in a UTI
- ) Sexual activity
- ) Urinary incontinence
- ) Faecal incontinence
- ) Constipation
Give 2 causes of increased binding of uropathogenic bacteria in a UTI
- ) Spermicide use
- ) Decreased oestrogen
- ) Menopause
Give a cause of a decreased urine flow in a UTI
- ) Dehydration
- ) Obstructed tract
Give 3 causes of increased bacterial growth in a UTI
- ) DM
- ) Immunosuppression
- ) Obstruction
- ) Stones
- ) Catheter
- ) Renal tract malformation
- ) Pregnancy
What is the main causative organism of UTIs?
E. coli
Give 4 symptoms of cystitis
- ) Frequency
- ) Dysuria
- ) Urgency
- ) Suprapubic pain
- ) Polyuria
- ) Haematuria
Give 4 symptoms of acute pyelonephritis
- ) Fever
- ) Rigor
- ) Vomiting
- ) Loin pain/tenderness
- ) Costovertebral pain
- ) Associated cystitis symptoms
- ) Septic shock
Give 4 symptoms of prostatitis
- ) Pain (perineum, rectum, scrotum, penis, bladder, lower back)
- ) Fever
- ) Malaise
- ) Nausea
- ) Urinary symptoms
- ) Swollen/tender prostate on PR
Give 2 signs of a UTI
- ) Fever
- ) Abdominal/loin tenderness
In who should we not rely on classical symptoms to diagnose a UTI?
Catheterised patients
When should we treat a UTI empirically?
Non pregnant women with 3 or more symptoms of cystitis and no vaginal discharge
Give 4 tests for a UTI
- ) Dipstick
- ) MSU culture
- ) Blood tests
- ) Imaging (USS)
What is the empirical treatment for a presumed E. coli infection?
Trimethoprium or nitrofuratoin
What antibiotic do we avoid in the 1st trimester?
Trimethoprim
What antibiotic do we avoid in the 3rd trimester?
Nitrofuratoin
What antibiotic do we treat an UUTI with?
Co-amoxiclv
What do erections result from?
Neuronal release of nitric oxide which, via cyclic GMP and Ca, hyperpolarises and thus relaxes vascular and trabecular smooth muscle cells, allowing engorgement
What is the nerve supply of the penis in an erection? (2)
POINT AND SHOOT
Parasympathetic S2-4 for erection
Sympathetic T11-L2 for ejaculation
Give the 3 main causes of erectile dysfunction (ED)
- ) Smoking
- ) Alcohol
- ) Diabetes
Give 4 other causes of ED
- ) Obesity
- ) Hyperthyroidism
- ) Hypogonadism
- ) MS
- ) Cord lesions
- ) Neuropathy
- ) Pelvic surgery
- ) Radiotherapy
- ) Prostatic hyperplasia
- ) Drugs
Give 2 drugs that can cause ED
- ) Digoxin
- ) Beta blockers
- ) Diuretics
- ) Antipsychotics
- ) Antidepressants
- ) Oestrogen’s
- ) Narcotics
What tests do we do in ED?
- ) Sexual and psychosocial history
- ) U&E, LFT, glucose, TFT, LH, FSH, lipids, testosteron, prolactin
- ) Doppler
- ) BP
- ) Genital examination
What is ED?
The persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance
What is the treatment for ED? (4)
- ) Treat causes
- ) Counselling
- ) Oral phosphodiesterase (PDE5) inhibitors (sildenafil, tadalafil)
- ) Vacuum aids, intracavernosal injections, transurethral pellets, prostheses
How do phosphodiesterase inhibitors work?
Increase cGMP
What is priapism?
Erection that lasts for longer than 4 hours
How do we treat priapism?
Aspirate corpora
What does ADPKD stand for?
Autosomal dominant polycystic kidney disease
Give 2 mutations that cause ADPKD, and when they will reach ESRF
PKD1, 50s
PKD2, 70s
What does ESRF stand for?
End stage renal failure
Give 3 renal symptoms of ADPKD
- ) Loin pain
- ) Visible haematuria
- ) Cyst infection
- ) Renal calculi
- ) High BP
- ) Progressive renal failure
Give 3 extrarenal symptoms of ADPKD
- ) Liver cysts
- ) Intracranial aneurysm > SAH
- ) Mitral valve prolapse
- ) Ovarian cyst
- ) Diverticular disease
How do we diagnose ADPKD?
USS to look for renal/liver cysts
What is the treatment for ADPKD? (5)
- ) Limit water intake
- ) Treat BP (not CCB)
- ) Treat infections
- ) Possible cyst decompression for pain
- ) Possible transplant
What do renal stones consist of?
Crystal aggregates
What are renal stones also known as?
Calculi, nephrolithiasis
Where are the 3 classic areas for renal stones to be deposited?
-) Pelviureteric junction
-) Pelvic brim
-) Vesicoureteric junction
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In which gender do renal stones occur more commonly in?
Male
What are renal stones made of?
- ) Calcium oxalate (75%)
- ) Magnesium ammonium phosphate (15%)
- ) Hydroxyapatite (5%)
Give 4 main symptoms of renal stones
- ) Pain - renal colic with N&V, obstruction symptoms
- ) Infection - fever, rigors, loin pain, nausea, vomiting
- ) Haematuria
- ) Proteinuria
- ) Sterile pyuria
- ) Anuria
What tests do we do for renal stones?
- ) FBC, U&E, Ca, PO4, glucose, bicarbonate, urate
- ) Urine dipstick
- ) MSU
- ) Non-contrast CT (or KUB XR
What does KUB XR stand for?
Kidney ureters bladder XR
What is the initial treatment for renal stones?
- ) Analgesia
- ) Fluids
- ) Antibiotics if infection
What is the treatment for stones <5mm in the lower ureter?
90-95% pass spontaneously, increase fluid
What is the treatment for stones >5mm/pain not resolving?
- ) Medical expulsive therapy (nifedipine or alpha blockers)
- ) Then extracorporeal shockwave lithotripsy (ESWL)
- ) Or ureteroscopy using a basket
- ) Percutaneous nephrolithotomy
Give an example of an alpha blocker
Tamsulosin
Give 2 ways we can prevent renal stones
- ) Drink plenty
- ) Normal dietary Ca intake (dairy)
- ) Reduce BMI, exercise
Give 3 classifications of a urinary tract obstruction (UTO)
- ) Partial, complete
- ) Unilateral, bilateral
- ) Luminal, mural, extra-mural
Give 2 examples of a luminal UTO
- ) Stones
- ) Tumour
- ) Blood clot
Give 2 examples of a mural UTO
- ) Stricture
- ) Neuromuscular dysfunction
Give 2 examples of an extra-mural UTO
- ) Abdominal/pelvic mass/tumour
- ) Retroperitoneal fibrosis
- ) Surgery
What 2 types of UTO require urgent treatment?
- ) Bilateral obstruction
- ) Obstruction with infection
What is hydronephrosis?
Presence of water in the kidneys due to obstruction
What is the equation for renal blood flow? (RBF)
RBF = (aortic pressure - renal venous pressure) / renal vascular resistance
Give a clinical feature of an acute UUTO
- ) Loin to groin pain
- ) May be superimposed infection, tenderness, enlarged kidney
Give 2 clinical features of a chronic UUTO
- ) Flank pain
- ) Renal failure
- ) Superimposed infection
- ) Polyuria
Give 2 clinical features of an acute LUTO
- ) Severe supra public pain
- ) +/- Acute confusion
- ) Often acute on chronic
- ) Distended, palpable bladder dull to percussion
Give 3 causes of an acute LUTO
- ) Prostatic obstruction
- ) Urethral strictures
- ) Anticholinergics
- ) Blood clots
- ) Alcohol
- ) Constipation
- ) Post op
- ) Infection
- ) Neurological
Give 2 clinical features of an chronic LUTO
- ) Frequency
- ) Hesitancy
- ) Poor stream
- ) Terminal dribbling
- ) Overflow incontinence
Give 2 signs of a chronic LUTO
- ) Distened, palapable bladder
- ) +/- Large prostate on PR
Give 3 causes of a chronic LUTO
- ) Prostatic enlargement
- ) Pelvic malignancy
- ) Rectal surgery
- ) DM
- ) CNS disease
Give 2 complications of a chronic LUTO
- ) UTI
- ) Urinary retention
- ) Renal failure
Give 3 tests for a UTO
- ) U&E, creatinine, FBC, PSA
- ) Urine dipstick
- ) US
- ) Radionuclide imaging for functional assessment
What is the treatment for an UUTO?
- ) Nephrostomy/ureteric stent
- ) Pyeloplasty to widen PUJ
What is the treatment for a LUTO?
- ) Urethral or suprapubic catheter
- ) Only catheterise in chronic if pain, infection, renal impairment
- ) Treat cause
What reduces stent related pain?
Alpha blockers
What is the pain like in renal colic?
- ) Loin to groin pain
- ) Intermittent colicky
What does the patient look like in renal colic?
Patient writhing
Where may the pain radiate to in renal colic?
Scrotum, labia, tip of penis
What occurs with renal colic?
Nausea, vomiting, sweating, haematuria
What is haematuria?
Blood in the urine
What is haematuria classified as?
- ) Visible (VH)
- ) Non visible (NVH)
Give 3 causes of haematuria
- ) Malignancy
- ) Calculi/stones
- ) IgA neuropathy
- ) Glomerulonephritis
- ) PKD
What is the management of haematuria?
-) Urological assessment, imaging, cytoscopy
What warrants repeat referral and investigation of haematuria? (2)
- ) Increasing proteinuria
- ) Deteriorating eGFR
Give 3 circumstances where we would refer someone to the suspected cancer pathway for bladder cancer
- ) >45 and unexplained VH
- ) VH that persists/recurs after successful treatment of UTI
- ) >60 with NVH and dysuria/raised WCC
What is the commonest malignancy in men aged 15-44?
Testicular tumours
Give 3 types of testicular tumour
- ) Seminoma (55%)
- ) Non-seminomatous germ cell tumour (NSGCT, 33%)
- ) Mixed germ cell tumour (12%)
- ) Lymphoma
Which testicular tumour occurs more in older people?
Seminoma (senile)
Which testicular tumour occurs more in younger people?
NSGCT (used to be teratoma, teenagers)
Give 2 risk factors for a testicular tumour
- ) Undescended testis
- ) Infant hernia
- ) Infertility
Give 4 signs of a testicular tumour
- ) Painless testis lump found after trauma/infection
- ) Haemospermia
- ) Secondary hydrocele
- ) Pain
- ) Dyspnoea (lung mets)
- ) Abdominal mass
- ) Effects of secreted hormones
What are the 4 stages of testicular tumours?
1) No evidence of mets
2) Infradiaphragmatic node involvement
3) Supradiaphragmatic node involvement
4) Lung involvement
How are nodal mets spread in testicular tumours?
Para-aortic nodes
What tests do we do to diagnose testicular tumours?
- ) CXR, CT
- ) Excision biopsy
- ) Tumour markers
What are the 2 tumour markers in testicular tumours?
Beta-hCG, alpha-FP
What does beta-hCG stand for?
Beta human chorionic gonadotropin
What does alpha-FP stand for?
Alpha fetoprotein
What is the treatment for a testicular tumour?
- ) Radical orchidectomy
- ) Radiotherapy (seminomas very radiosensitive)
- ) Possible semen collection for future
What 3 drugs do we use in the chemotherapy for NSGCTs?
- ) Bleomycin
- ) Etoposide
- ) Cisplatin
Give 2 associations with prostate cancer
- ) Positive family history
- ) Increased testosterone
What is the most common type of prostate cancer
Adenocarcinoma
Where do prostate adenocarcinomas arise?
Peripheral prostate
Give 3 ways prostate cancer can spread
- ) Local (seminal vesicles, bladder, rectum)
- ) Lymph
- ) Haematogenously
Give 3 symptoms of prostate cancer
- ) Asymptomatic
- ) Nocturia
- ) Hesitancy
- ) Poor stream
- ) Terminal dribbling
- ) Obstruction
- ) Weight loss and bone pain suggest mets
What does a PR/DRE exam show in prostate cancer?
Hard, irregular prostate
How do we diagnose prostate cancer?
- ) Increased PSA
- ) Transrectal US and biopsy
- ) Bone scan
- ) CT/MRI (MRI to stage)
What does PSA do?
Prostate specific antigen liquefies the semen
What grading system do we do in prostate cancer?
Gleason grading (add 2 most common grades together)
What is the difference between grade and stage in relation to cancers?
Grade - biological aggressiveness
Stage - extent of disease
What is the treatment for prostate cancer?
- ) Radical prostatectomy
- ) Radical radiotherapy
- ) Hormone therapy
- ) Active surveillance
- ) Analgesia
- ) Treat hypercalcaemia
What tests are done in the screening for prostate cancer? (3)
DRE, transracial US, PSA
Where does renal cell carcinoma arise from? (RCC)
Proximal renal tubular epithelium
What is a major risk factor for RCC?
Haemodialysis
What does RCC present with?
- ) 50% found incidentally
- ) Haematuria
- ) Loin pain
- ) Abdominal mass
- ) Anorexia, malaise, weight loss
- ) Pyrexia of unknown origin
- ) Varicocele rarely
What are the tests for RCC? (5)
- ) BP increased from renin secretion
- ) FBC shows polycythaemia from EPO secretion
- ) ESR, U&E, ALP
- ) Urine RBCs, cytology
- ) US, CT/MRI, CXR
What is the treatment for RCC? (4)
- ) Radical nephrectomy
- ) Chemotherapy and radio frequency ablation for unfit/unwilling patients
- ) Generally radio/chemo resistant
- ) High dose IL-2, anti-angiogenesis agents, mTOR inhibitors for non resectable
What is the Mayo prognostic risk score in RCC?
SSIGN Predicts survival by looking at -) State -) Size -) Grade -) Necrosis
What are the 4 stages of RCC?
I - <7cm, kidney
II - >7cm, kidney
III - outside kidney, local spread
IV - outside kidney, metastatic spread
Give an anti-angiogenesis agent
Pazopanib, sunitnib, axitinib
What are the majority of bladder cancers? (>90%)
Transitional cell carcinomas (TTC)
What are the 3 grades of TTCs?
1 - differentiated
2- intermediate
3 - poorly differentiated
Give 2 presenting features of bladder tumours
- ) Painless haematuria
- ) Recurrent UTIs
- ) Voiding irritability
Give 3 associations with bladder tumours
- ) Smoking
- ) Aromatic amines (rubber)
- ) Chronic cystitis
- ) Schistosomiasis (increased risk of squamous cell carcinoma)
- ) Pelvic irradiation
What increases morbidity in bladder cancer?
Penetrating muscle (20%
What are the stages of bladder cancer? (T6)
Tis - carcinoma in situ Ta - epithelium only T1 - submucosa/lamina propria T2 - muscle T3 - perivesical fat T4 - adjacent organs
Give some tests we can do for bladder tumours
- ) Cystoscopy with biopsy is diagnostic
- ) Urine MC&S
- ) CT urogram
How do we treat Tis/Ta/T1 TCC of the bladder? (2)
- ) Diathermy (heat/electricity) via transurethral cytoscopy/transuretheral resection of bladder tumour
- ) Consider intravesical BCG (stimulates non-specific immune response)
How do we treat T2, T3 TCC of the bladder? (3)
- ) Radical cystectomy best
- ) Radiotherapy
- ) Post-op chemo (M-VAC)
What is the M-VAC chemotherapy treatment?
Methotrexate
Vinblastine
Doxorubicin
Cisplatin
How do we treat T4 TCC of the bladder? (2)
- ) Palliative chemo/radio
- ) Chronic catheterisation and urinary diversions for pain
Where does local spread of TTC go?
Pelvic structures
Where does lymphatic spread of TTC go?
Iliac and para-aortic nodes
Where does haematogenous spread of TTC go?
Liver and lungs
What is acute kidney injury? (AKI)
A syndrome of decreased renal function over hours-days
How is AKI measured?
Serum creatinine or urine output
Give the 3 diagnostic definitions of AKI
- ) Rise in creatinine >26μmol/L within 48h
- ) Rise in creatinine >1.5 x baseline within 7 days
- ) Urine output <0.5mL/kg/h for >6 hours
Give 3 risk factors for AKI
- ) CKD
- ) Age
- ) Male
- ) Comorbidity (DM, CVD, malignancy, chronic liver disease, complex surgery)
Give 4 causes of AKI
- ) Sepsis
- ) Major surgery
- ) Cardiogenic shock
- ) Other hypovolaemia
- ) Drugs
- ) Hepatorenal syndrome
- ) Obstruction
What are the 3 aetiology categories of AKI, and give a cause for each
- ) Pre-renal, decreased perfusion to kidney
- ) Renal, intrinsic renal disease
- ) Post-renal, obstruction to urine
What tests do we do for AKI?
- ) Drugs history
- ) Urine dipstick
- ) FBC, U&E, LFT, clotting, CK, CRP, ABG
- ) Renal US
How do we treat AKI?
- ) Correct pre and post renal factors
- ) Treat hyperkalaemia
- ) Pulmonary oedema with loop diuretics (furosemide)
- ) Daily monitoring
- ) Haemodialysis/haemofiltration
How do we treat hyperkalaemia?
Give insulin (drives potassium into cell) and dextrose (don’t want hypocalcaemia)
What do we give to treat the heart in hyperkalaemia?
Calcium gluconaete
What is chronic kidney disease? (CKD)
Abnormal kidney structure or function, present for >3 months, with implications for health
What is CKD based on? (3)
- ) GFR category
- ) Presence of albuminuria as a marker of kidney damage
- ) Cause of kidney disease
What are the stages of CKD, based on GFR? (6)
G1 - >90, only CKD if other evidence of kidney damage
G2 - 60-89, only CKD if other evidence of kidney damage
G3a - 45-59, mild-moderate
G3b - 30-44, moderate-severe
G4 - 15-29, severe
G5 - <15, kidney failure
Give the 3 most common causes of CKD
- ) Diabetes
- ) Glomerulonephritis
- ) Increased BP/renovascular disease
What are decreased GFR and albuminuria independently associated with a higher risk of?
- ) All cause mortality
- ) Cardiovascular and mortality
- ) Progressive kidney disease and kidney failure
- ) AKI
Give 4 symptoms of CKD
- ) Anorexia
- ) SOB
- ) Peripheral oedema
- ) Nausea
- ) Vomiting
- ) Restless legs
- ) Fatigue
- ) Weakness
- ) Pruritus
- ) Bone pain
- ) Amenorrhoea
- ) Impotence
In which stage does CKD become symptomatic?
G4
Give 3 signs of CKD
- ) Oliguria
- ) Dyspnoea
- ) Increased BP
- ) Cardiomegaly
What 2 things are decreased in a blood test in CKD?
- ) Hb (normocytic anaemia)
- ) Calcium
What 2 things are increased in a blood test in CKD?
- ) Phosphate
- ) PTH
What tests do we do for CKD?
- ) Blood
- ) Urine dipstick (Bence Jones)
- ) USS
- ) Renal biopsy
What does a US show in CKD?
- ) Small except in infiltrative disorders, APKD, DM
- ) Consider reno vascular disease if asymmetrical
- ) Poor corticomedullary differentiation
What can untreated CKD present with?
- ) Severe uraemia
- ) Hyperkalaemia causing arrhythmias
- ) Encephalopathy
- ) Seizures
- ) Coma
What is the treatment of CKD? (7)
- ) BP treatment target <140/90
- ) Control glucose
- ) Lifestyle advice (salt decreased)
- ) Treat anaemia, acidosis, oedema, bone mineral disorders, restless legs/cramps
- ) Treat CVD complications
- ) Possible transplant
- ) Haemodialysis, haemofiltration
What is glomerulonephritis? (GN) (5)
Encompasses a number of conditions which:
- ) Are caused by pathology in the glomerulus
- ) Present with proteinuria, haematuria, both
- ) Diagnosed on renal biopsy
- ) Cause CKD
- ) Can progress to kidney failure (except minimal change)
What is nephrosis?
Proteinuria due to podocyte pathology
What is nephritis?
Haematuria due to inflammatory damage
What can occur if GN causes scarring?
Proteinuria
What is the treatment for GN?
BP control and inhibition of renin-angiotensin axis
What is IgA nephropathy?
Commonest primary GN in high income countries
What is the presentation of IgA nephropathy?
- ) Asymptomatic NVH
- ) Episodic VH within 12-72h of infection
- ) Increased BP
How do we diagnose IgA nephropathy?
Renal biopsy shows IgA deposition in mesangium
What is the treatment for IgA nephropathy?
- ) ACEI/ARB reduce proteinuria and protect renal function
- ) Corticosteroids and fish oil if persistent proteinuria
What is the triad of presentation of nephritic syndrome?
- ) Moderate/severe increased BP
- ) Haematuria
- ) Moderate/severe decreased GFR
What is the triad of presentation of nephrotic syndrome?
- ) Hypoalbuminaemia
- ) Proteinuria
- ) Oedema
Give 2 primary causes of nephritic syndrome
- ) IgA nephropathy
- ) Mesangiocapillary glomerulonephritis
Give 2 secondary causes of nephritic syndrome
- ) Streptococcal infection
- ) Vasculitis
- ) SLE
- ) Cryoglobulinaemia
- ) Anti GBM disease (Goodpasture’s)
Give 3 primary causes of nephrotic syndrome
- ) Minimal change disease
- ) Membranous nephropathy
- ) Focal segmental glomerulosclerosis (FSGS)
- ) Membranoproliferative GN
Give 2 secondary causes of nephrotic syndrome
- ) DM
- ) Lupus nephritis
- ) Myeloma
- ) Amyloid
- ) Pre-eclampsia
What is the filtration barrier of the kidney formed by? (3)
- ) Podocytes
- ) Glomerular basement membrane
- ) Endothelial cells
What is the pathophysiology of nephrotic syndrome?
Proteinuria resulting from podocyte pathology:
-) Abnormal function in minimal change disease
-) Immune mediated damage in membranous nephropathy
-) Podocyte injury/death in FSGS
Proteinuria resulting from GBM/endothelial cell pathology:
-) Membranoproliferative GN
What is the presenting feature of nephrotic syndrome?
Generalised pitting oedema
How do we treat nephrotic syndrome? (4)
- ) Reduce oedema - loop diuretics
- ) Treat underlying cause
- ) Reduce proteinuria - ACEI
- ) Treat complications - statins, aspirin
Give 2 complications of nephrotic syndrome
- ) Thromboembolism
- ) Infection
- ) Hyperlipidaemia
How do we reduce oedema?
- ) Fluid and salt restriction
- ) Loop diuretics (furosemide)
How do we reduce proteinuria?
ACEI/ARB
How do we treat a thromboembolism?
Heparin and wararin
What is the most common cause of nephrotic syndrome in children?
Minimal change disease
Give 3 things membranous nephropathy can be secondary to
- ) Malignancy
- ) Infection
- ) Immunological
- ) Drugs
How do we diagnose membranous nephropathy?
Anti-phospholipase A2 receptor antibody in idiopathic disease
What does a biopsy show in membranous nephropathy?
Diffusely thickened GBM due to sub epithelial deposits
What is the treatment for membranous nephropathy?
- ) ACE/ARB and BP control
- ) Immunosuppression in high risk of progression
Give 3 causes of minimal change disease
- ) Idiopathic (most)
- ) Drugs (NSAIDs, lithium)
- ) Paraneoplastic (Hodgkin’s lymphoma)
What does electron microscopy show in minimal change disease?
Effacement of podocyte foot processes (no longer tight)
How do we treat minimal change disease?
- ) Prenisolone (high relapse rate)
- ) Cyclophosphamide for frequent relapses
What is the commonest GN seen on renal biopsy?
Focal segmental glomerulosclerosis, FSGS
Give 3 secondary causes of FSGS
- ) HIV
- ) Heroin
- ) Lithium
- ) Lymphoma
- ) Any cause of decreased kidney mass/nephrons
- ) Kidney scarring
Which nephrotic GN doesn’t lead to renal failure?
Minimal change disease
How do we diagnose FSGS?
Glomeruli have scarring of certain segments (focal sclerosis)
How do we treat FSGS? (3)
- ) ACEI/ARB and BP control
- ) Corticosteroids only in idiopathic disease
- ) Plasma exchange and rituximab for recurrence in transplants
What is the equation for STI/HIV transmission?
R=BCD R - reproductive rate B - infectivity rate C - partners over time D - duration of infection
What does chlamydia affect in neonates?
Conjunctiva
What is the infecting organism in chlamydia?
Chlamydia trachomatis
What are the symptoms in males with chlamydia? (2)
- ) Dysuria
- ) Urethral discharge
What is the % transmission of male to female and female to male in chlamydia?
70%
Give 2 complications of males with chlamydia
- ) Epididymo-orchititis
- ) Reactive arthritis
Give 2 symptoms in females with chlamydia
- ) Discharge
- ) Menstrual irregularity
- ) Dysuria
In whom is chlamydia more asymptomatic?
Females
Give 2 complications of females with chlamydia
- ) Pelvic inflammatory disease
- ) Neonatal transmission
- ) Fitz Hugh Curtis syndrome
How do we diagnose chlamydia?
- ) Nucleic acid amplification tests
- ) Vaginal and endocervical swab - women
- ) First void urine - men
How do we treat chlamydia? (2)
- ) Azithromycin or doxycycline
- ) Eryhtomycin or azithromycin in pregnancy
Which is the most common STI?
Chlamydia
How does gonorrhoea present in males? (2)
- ) Dysuria
- ) Urethral discharge
How does gonorrhoea present in females? (3)
- ) Discharge
- ) Menstrual irregularity
- ) Dysuria
Give 2 complications of gonorrhoea in females
- ) Pelvic inflammatory disease
- ) Neonatal transmission
- ) Fitz Hugh Curtis syndrome
What does pelvic inflammatory disease include? (3)
- ) Tubal factor infertility
- ) Ectopic pregnancy
- ) Chronic pelvic pain
Give a neonatal transmission (STIs)
- ) Ophthalmia neonatorum
- ) Atypical pneumonia
How do we diagnose gonorrhoea?
Same as for chlamydia
What is the causative organism in gonorrhoea?
Neisseria gonorrhoeae
What STI often occurs in a relationship, and which is associated with recent partner change?
Relationship - chlamydia
Change - gonorrhoea
What can gonorrhoea cause in babies?
Blindness
What is the causative organism in syphilis?
Treponema pallidum
What are the 3 presentations of syphilis?
- ) Primary (<90d after inoculation)
- ) Secondary (4-10 weeks)
- ) Tertiary (20-40y)
What is the presentation of primary syphilis?
-) Macule > papuule > typically painless ulcer (chancre)
What is the presentation of secondary syphilis? (4)
- ) Rash
- ) Mucous patches
- ) Condyloma late (raised pale plaques)
- ) Systemic - fever, headache, myalgia, lymphadenopathy, hepatitis
What is the presentation of tertiary syphilis? (3)
- ) Neurosyphilis - aseptic meningitis, focal neurological deficits, seizures, psychiatric symptoms
- ) Gummatous syphilis - destructive granulomata in skin, mucous membranes, bones, viscera
- ) Cardiovascular - aortitis, aortic regurgitation/aneurysm
What is the biggest risk group for syphilis?
Men having sex with men
How do we diagnose syphilis?
- ) PCR, serology
- ) T. palladim as antigen
How do we treat syphilis?
IM benzylpenicillin
What is primary prevention?
Prevent onset of disease
What is secondary prevention?
Detect and treat disease early
What is tertiary prevention?
Reduce long term effects of disease
What is pre-exposure prophylaxis of HIV?
PrEP
Give 4 LUTS
Storage symptoms:
-) Frequency, nocturne, urgency, urgency incontinenece
Voiding symptoms:
-) Hesitancy, straining, poor/intermittent stream, incomplete emptying
Other:
-) Post micturition dribbling, haematuria, dysuria
How do we treat an acute retention of urine?
Catheterisation
Where do the kidneys lie?
Retroperitoneal, T11-L3
Where do the ureters run?
Over the poses muscle, cross the iliac vessels at the pelvic brim and insert into the trigone of the bladder
What type of control does the pelvic nerve have (P/S) of the bladder and sphincter, and what are its roots?
- ) Parasympathetic
- ) S2-4
What type of control does the hypogastric plexus have (P/S) of the bladder and sphincter, and what are its roots?
- ) Sympathetic
- ) T11-L2
What type of control does the pudendal nerve have (P/S) of the bladder and sphincter, and what are its roots?
- ) Somatic
- ) S2-4
What type of nerve is the afferent pelvic nerve, and where is it from?
- ) Sensory nerve
- ) From detrusor muscle
What are the 4 main nerves involved in the control of the bladder and sphincter?
- ) Pelvic/parasympathetic nerve
- ) Hypogastric plexus/sympathetic nerve
- ) Pudendal/somatic nerve
- ) Afferent pelvic nerve
What are the 4 main control centres involved in the control of the bladder and sphincter?
- ) Cortex
- ) Pontine micturition centre/periaqueductal grey
- ) Sacral micturition centre
- ) Onuf’s nucleus
What role does the cortex have in the control of the bladder and sphincter?
Voluntary control
What role does the pontine micturition centre/PAG have in the control of the bladder and sphincter?
Coordination of voiding
What role does the sacral micturition centre have in the control of the bladder and sphincter?
Micturition reflex
What role does Onuf’s nucleus have in the control of the bladder and sphincter?
Guarding reflex
Why does the pressure in the bladder remain low as the volume increases?
Receptive relaxation and detrusor muscle compliance
What are the steps of the filling phase? (4)
1) Low volumes
2) Afferent pelvic nerve sends slow firing signals to pons via spinal cord
3) Sympathetic nerve stimulation maintains detrusor muscle relaxation
4) Somatic nerve stimulation maintains urethral sphincter contraction
What are the steps of the voiding phase? (5)
1) Autonomic spinal reflex
2) Low volumes
3) Afferent pelvic nerve sends fast firing signals to the sacral micturition centre
4) Parasympathetic nerve stimulated and detrusor muscle contracts
5) Pudendal/somatic nerve inhibited, external sphincter relaxes
What is the guarding reflex?
Voluntary control of micturition in anatomically an functionally normal adults when it is inappropriate to void
Give the 3 determinants of fluid movement
- ) Hydrostatic pressure
- ) Osmotic presure
- ) Oncotic pressure
What is hypo/hypervolaemia?
Too little/too much fluid
What is the pulse like in hypovolaemia?
Tachycardic
What occurs to creatinine and haemoglobin in hypo/hypervolaemia?
Hypo - increased
Hyper - decreased
Give 3 sites of fluid accumulation
- ) Pulmonary oedema
- ) Pleural effusion
- ) Ascites
- ) Intraabdominal collection/bleeds
Give 2 risk factors for hypovolaemia
- ) Elderly
- ) Ileostomy/colostomy
- ) Short bowel syndrome
- ) Bowel obstruction
- ) Diuretics
Give 2 risk factors for hypervolaemia
- ) AKI
- ) CKD
- ) HF
- ) Liver failure
How do we treat hypovolaemia? (3)
- ) Fluid
- ) Treat cause
- ) Crystalloid or colloid fluid
How do we treat hypervolaemia? (3)
- ) Fluid restriction
- ) Treat cause
- ) Diuretics
What should not be prescribed in kidney failure patients, and why?
Hartmann’s solution, contains potassium
Where do loop diuretics work?
Loop of Henle
Where do thiazide diuretics work?
Distal tubule
Where do aldosterone antagonists work?
Collecting duct
Give an example of an aldosterone antagonist
- ) Spironolactone
- ) Potassium sparing diuretic
What drugs block aquaporins?
Vasopressin antagonists
What can renal artery stenosis lead to?
Severe hypertension (kidney thinks BP is too low)
What do NSAIDs reduce the amount of?
Prostaglandin
What does prostaglandin do to the glomerulus?
Preferentially dilates the afferent arteriole
What does angiotensin II do to the glomerulus?
Preferentially constricts the efferent arteriole
Why should we not prescribe NSAIDs with angiotensin II inhibitors?
Drops pressure in glomerulus by
-) Less blood in - NSAIDs
-) More blood out - angiotensin II inhibitors
GFR dramatic decrease, kidney failure
You got this?
Ofc
What protein is found on a dipstick in CKD?
Bence Jones
What is the mutation in ARPKD?
PKHD1
