Urogenital and renal Flashcards
1
Q
Give 3 symptoms of testicular torsion
A
- ) Sudden onset of pain in one testis (walking uncomfortable)
- ) Abdominal pain
- ) Nausea
- ) Vomiting
2
Q
Give 2 signs of testicular torsion
A
- ) Inflammation of one tests - tender, hot, swollen
- ) Testis may lay high and transversely
3
Q
Between what ages is testicular torsion more common?
A
11-30
4
Q
What is the main differential diagnoses of testicular torsion?
A
Epididymo-orchitis
5
Q
What do we do to diagnose testicular torsion?
A
Doppler US may demonstrate lack of blood flow to testes
6
Q
What is our immediate thought when someone presents with a suspected testicular torsion?
A
Immediate surgery
7
Q
What is the treatment for testicular torsion?
A
Possible orchidectomy and bilateral fixation - expose and untwist, fix to scrotum
8
Q
What is a hydrocele?
A
Fluid within the tunica vaginalis
9
Q
What is primary hydrocele associated with?
A
Processus vaginalis (typically resolves in 1st year)
10
Q
Give 2 causes of a secondary hydrocele
A
- ) Tumour
- ) Trauma
- ) Infection
11
Q
Which type of hydrocele is more common and larger?
A
Primary
12
Q
How do we treat hydroceles?
A
Aspiration or surgery
13
Q
What is a varicocele?
A
Dilated veins of the pam-uniform plexus
14
Q
Which side is more commonly affected by varicoceles?
A
Left
15
Q
What do varicoceles present as?
A
Often visible as distended scrotal blood vessels that feel like ‘a bag of worm’s, possible dull ache
16
Q
What are varicoceles associated with?
A
Subfertility
17
Q
How do we repair varicoceles?
A
Surgery or embolisation
18
Q
What are epididymal cysts?
A
Contain clear/milky (spermatocele) fluid
19
Q
When do epididymal cysts usually develop?
A
Adulthood
20
Q
Where do epididymal cysts usually occur?
A
Above and behind testes
21
Q
How do we treat symptomatic epididymal cysts?
A
Remove
22
Q
What is epididymo-orchitis?
A
Inflammation of the epididymis and testes
23
Q
What is epididymitis?
A
Inflammation of the epididymis
24
Q
Give 3 causes of epididymo-orchitis
A
- ) Chlamydia
- ) E. coli
- ) Mumps
- ) N. gonorrhoea
- ) TB
25
Give 3 symptoms of epididymo-orchitis
- ) Sudden-onset tender swelling
- ) Dysuria
- ) Sweats/fever
- ) UTI/STI symptoms
26
How do we treat epididymo-orchitis? (4)
- ) Antibiotics
- ) Analgesia
- ) Scrotal support
- ) Drainage of any abscess
27
What antibiotics do we give in epididymo-orchitis? (3)
- ) <35 doxycycline
- ) Ceftriaxone if gonorrhoea
- ) >35 (non STI) ciprofloxacin/ofloxacin
28
How may the organism infect in epididymo-orchitis?
- ) Retrograde spread from prostatic urethra and seminal vesicles
- ) Bloodstream (less common)
29
How do we diagnose epididymis-orchitis?
MSU and STI screen
30
If we cannot get above a scrotal mass, what is it?
Inguinoscrotal hernia or hydrocele extending proximally
31
If a scrotal mass is separate and cystic, what is it?
Epididymal cyst
32
If a scrotal mass is separate and solid, what is it?
Epididymitis/varicocele
33
If a scrotal mass is testicular and cystic, what is it?
Hydrocele
34
If a scrotal mass is testicular and solid, what is it?
Tumour, haematocele, granuloma, orchitis, gumma
35
What is a haematocele?
Blood in tunica vaginalis
36
What does a haematocele follow?
Trauma
37
How do we treat a haematocele?
Drainage/excision
38
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)
39
Give 4 symptoms of BPH
LUTS
- ) Nocturia
- ) Frequency
- ) Urgency
- ) Post-micturition dribbling
- ) Poor stream/flow
- ) Hesitancy
- ) Overflow incontinence
- ) Haematuria
- ) Bladder stones
- ) UTI
40
How do we test for BPH?
- ) PR exam
- ) MSU
- ) U&E
- ) US
- ) PSA
- ) Biopsy
41
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
42
How do alpha-blockers work in the treatment of BPH?
Decrease smooth muscle tone of prostate and bladder
43
How do 5-alpha-reductase inhibitors work in the treatment of BPH?
Reduce conversion of testosterone to the more potent androgen dehydrogenase
44
What should patients use when using 5-alpha-reductase inhibitors?
Condoms - excreted in semen
45
What are our surgical options for BPH?
- ) Transurethral resection of prostate (TURP)
- ) Transurethral incision of prostate (TUIP)
- ) Retropubic prostatectomy
- ) Transurethral laser induced prostatectomy (TULIP)
46
What is the major cause of incontinence in men?
Enlargement of the prostate
47
What surgery in men may cause incontinence?
TURP
48
What is functional incontinence?
Too slow in finding the toilet due to immobility or unfamiliar surroundings
49
What is stress incontinence?
Leakage from an incompetent sphincter (e.g in coughing, laughing, pregnancy, after birth)
50
Give 2 risk factors for stress incontinence
- ) Age
| - ) Obesity
51
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
52
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
53
Give 3 things that can precipitate urgency/leaking
- ) Arriving home
- ) Cold
- ) Sound of running water
- ) Caffeine
- ) Obesity
54
What is the cause for urge incontinence/overactive bladder?
Detrusor overactivity
55
Give 3 treatments for detrusor overactivity
- ) Antimuscarinics
- ) Topical oestrogens
- ) Beta 3 adrenergic agonist
- ) Intravesical botulinum toxin
- ) Surgery
- ) Bladder training
56
Give 2 other causes for urge incontinence/overactive bladder
- ) Urinary infection
- ) Diabetes
- ) Diuretics
- ) Atrophic vaginitis
- ) Urethritis
57
What is continuous incontinence due to?
Due to fistula (between vagina and bladder)
58
In who does social incontinence occur?
Dementia, confusion, sedation
59
How do we treat stress incontinence?
- ) Pelvic floor exercises
- ) Intravaginal electrical stimulation
- ) Surgery
- ) Duloxetine
60
How do we treat urge incontinence?
- ) Examine for spinal cord and CNS signs, vaginitis
- ) Bladder training
- ) Weight loss
- ) Aids, absorbant pads
61
How can we treat vaginitis?
Topical oestrogen therapy
62
What is bacteriuria?
Bacteria in the urine (symptomatic/asymptomatic)
63
Give 2 lower UTIs
- ) Cystitis (bladder)
| - ) Prostatitis (prostate)
64
Give an upper UTI
Pyelonephritis (kidney/renal pelvis)
65
What is bacterial cystitis/urethral syndrome?
A diagnosis of exclusion in patients with dysuria and frequency
66
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
67
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
68
Give 2 causes for bacterial inoculation in a UTI
- ) Sexual activity
- ) Urinary incontinence
- ) Faecal incontinence
- ) Constipation
69
Give 2 causes of increased binding of uropathogenic bacteria in a UTI
- ) Spermicide use
- ) Decreased oestrogen
- ) Menopause
70
Give a cause of a decreased urine flow in a UTI
- ) Dehydration
| - ) Obstructed tract
71
Give 3 causes of increased bacterial growth in a UTI
- ) DM
- ) Immunosuppression
- ) Obstruction
- ) Stones
- ) Catheter
- ) Renal tract malformation
- ) Pregnancy
72
What is the main causative organism of UTIs?
E. coli
73
Give 4 symptoms of cystitis
- ) Frequency
- ) Dysuria
- ) Urgency
- ) Suprapubic pain
- ) Polyuria
- ) Haematuria
74
Give 4 symptoms of acute pyelonephritis
- ) Fever
- ) Rigor
- ) Vomiting
- ) Loin pain/tenderness
- ) Costovertebral pain
- ) Associated cystitis symptoms
- ) Septic shock
75
Give 4 symptoms of prostatitis
- ) Pain (perineum, rectum, scrotum, penis, bladder, lower back)
- ) Fever
- ) Malaise
- ) Nausea
- ) Urinary symptoms
- ) Swollen/tender prostate on PR
76
Give 2 signs of a UTI
- ) Fever
| - ) Abdominal/loin tenderness
77
In who should we not rely on classical symptoms to diagnose a UTI?
Catheterised patients
78
When should we treat a UTI empirically?
Non pregnant women with 3 or more symptoms of cystitis and no vaginal discharge
79
Give 4 tests for a UTI
- ) Dipstick
- ) MSU culture
- ) Blood tests
- ) Imaging (USS)
80
What is the empirical treatment for a presumed E. coli infection?
Trimethoprium or nitrofuratoin
81
What antibiotic do we avoid in the 1st trimester?
Trimethoprim
82
What antibiotic do we avoid in the 3rd trimester?
Nitrofuratoin
83
What antibiotic do we treat an UUTI with?
Co-amoxiclv
84
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
85
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
86
Give the 3 main causes of erectile dysfunction (ED)
- ) Smoking
- ) Alcohol
- ) Diabetes
87
Give 4 other causes of ED
- ) Obesity
- ) Hyperthyroidism
- ) Hypogonadism
- ) MS
- ) Cord lesions
- ) Neuropathy
- ) Pelvic surgery
- ) Radiotherapy
- ) Prostatic hyperplasia
- ) Drugs
88
Give 2 drugs that can cause ED
- ) Digoxin
- ) Beta blockers
- ) Diuretics
- ) Antipsychotics
- ) Antidepressants
- ) Oestrogen's
- ) Narcotics
89
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
90
What is ED?
The persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance
91
What is the treatment for ED? (4)
- ) Treat causes
- ) Counselling
- ) Oral phosphodiesterase (PDE5) inhibitors (sildenafil, tadalafil)
- ) Vacuum aids, intracavernosal injections, transurethral pellets, prostheses
92
How do phosphodiesterase inhibitors work?
Increase cGMP
93
What is priapism?
Erection that lasts for longer than 4 hours
94
How do we treat priapism?
Aspirate corpora
95
What does ADPKD stand for?
Autosomal dominant polycystic kidney disease
96
Give 2 mutations that cause ADPKD, and when they will reach ESRF
PKD1, 50s
| PKD2, 70s
97
What does ESRF stand for?
End stage renal failure
98
Give 3 renal symptoms of ADPKD
- ) Loin pain
- ) Visible haematuria
- ) Cyst infection
- ) Renal calculi
- ) High BP
- ) Progressive renal failure
99
Give 3 extrarenal symptoms of ADPKD
- ) Liver cysts
- ) Intracranial aneurysm > SAH
- ) Mitral valve prolapse
- ) Ovarian cyst
- ) Diverticular disease
100
How do we diagnose ADPKD?
USS to look for renal/liver cysts
101
What is the treatment for ADPKD? (5)
- ) Limit water intake
- ) Treat BP (not CCB)
- ) Treat infections
- ) Possible cyst decompression for pain
- ) Possible transplant
102
What do renal stones consist of?
Crystal aggregates
103
What are renal stones also known as?
Calculi, nephrolithiasis
104
Where are the 3 classic areas for renal stones to be deposited?
-) Pelviureteric junction
-) Pelvic brim
-) Vesicoureteric junction
LEARN THIS
105
In which gender do renal stones occur more commonly in?
Male
106
What are renal stones made of?
- ) Calcium oxalate (75%)
- ) Magnesium ammonium phosphate (15%)
- ) Hydroxyapatite (5%)
107
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
108
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
109
What does KUB XR stand for?
Kidney ureters bladder XR
110
What is the initial treatment for renal stones?
- ) Analgesia
- ) Fluids
- ) Antibiotics if infection
111
What is the treatment for stones <5mm in the lower ureter?
90-95% pass spontaneously, increase fluid
112
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
113
Give an example of an alpha blocker
Tamsulosin
114
Give 2 ways we can prevent renal stones
- ) Drink plenty
- ) Normal dietary Ca intake (dairy)
- ) Reduce BMI, exercise
115
Give 3 classifications of a urinary tract obstruction (UTO)
- ) Partial, complete
- ) Unilateral, bilateral
- ) Luminal, mural, extra-mural
116
Give 2 examples of a luminal UTO
- ) Stones
- ) Tumour
- ) Blood clot
117
Give 2 examples of a mural UTO
- ) Stricture
| - ) Neuromuscular dysfunction
118
Give 2 examples of an extra-mural UTO
- ) Abdominal/pelvic mass/tumour
- ) Retroperitoneal fibrosis
- ) Surgery
119
What 2 types of UTO require urgent treatment?
- ) Bilateral obstruction
| - ) Obstruction with infection
120
What is hydronephrosis?
Presence of water in the kidneys due to obstruction
121
What is the equation for renal blood flow? (RBF)
RBF = (aortic pressure - renal venous pressure) / renal vascular resistance
122
Give a clinical feature of an acute UUTO
- ) Loin to groin pain
| - ) May be superimposed infection, tenderness, enlarged kidney
123
Give 2 clinical features of a chronic UUTO
- ) Flank pain
- ) Renal failure
- ) Superimposed infection
- ) Polyuria
124
Give 2 clinical features of an acute LUTO
- ) Severe supra public pain
- ) +/- Acute confusion
- ) Often acute on chronic
- ) Distended, palpable bladder dull to percussion
125
Give 3 causes of an acute LUTO
- ) Prostatic obstruction
- ) Urethral strictures
- ) Anticholinergics
- ) Blood clots
- ) Alcohol
- ) Constipation
- ) Post op
- ) Infection
- ) Neurological
126
Give 2 clinical features of an chronic LUTO
- ) Frequency
- ) Hesitancy
- ) Poor stream
- ) Terminal dribbling
- ) Overflow incontinence
127
Give 2 signs of a chronic LUTO
- ) Distened, palapable bladder
| - ) +/- Large prostate on PR
128
Give 3 causes of a chronic LUTO
- ) Prostatic enlargement
- ) Pelvic malignancy
- ) Rectal surgery
- ) DM
- ) CNS disease
129
Give 2 complications of a chronic LUTO
- ) UTI
- ) Urinary retention
- ) Renal failure
130
Give 3 tests for a UTO
- ) U&E, creatinine, FBC, PSA
- ) Urine dipstick
- ) US
- ) Radionuclide imaging for functional assessment
131
What is the treatment for an UUTO?
- ) Nephrostomy/ureteric stent
| - ) Pyeloplasty to widen PUJ
132
What is the treatment for a LUTO?
- ) Urethral or suprapubic catheter
- ) Only catheterise in chronic if pain, infection, renal impairment
- ) Treat cause
133
What reduces stent related pain?
Alpha blockers
134
What is the pain like in renal colic?
- ) Loin to groin pain
| - ) Intermittent colicky
135
What does the patient look like in renal colic?
Patient writhing
136
Where may the pain radiate to in renal colic?
Scrotum, labia, tip of penis
137
What occurs with renal colic?
Nausea, vomiting, sweating, haematuria
138
What is haematuria?
Blood in the urine
139
What is haematuria classified as?
- ) Visible (VH)
| - ) Non visible (NVH)
140
Give 3 causes of haematuria
- ) Malignancy
- ) Calculi/stones
- ) IgA neuropathy
- ) Glomerulonephritis
- ) PKD
141
What is the management of haematuria?
-) Urological assessment, imaging, cytoscopy
142
What warrants repeat referral and investigation of haematuria? (2)
- ) Increasing proteinuria
| - ) Deteriorating eGFR
143
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
144
What is the commonest malignancy in men aged 15-44?
Testicular tumours
145
Give 3 types of testicular tumour
- ) Seminoma (55%)
- ) Non-seminomatous germ cell tumour (NSGCT, 33%)
- ) Mixed germ cell tumour (12%)
- ) Lymphoma
146
Which testicular tumour occurs more in older people?
Seminoma (senile)
147
Which testicular tumour occurs more in younger people?
NSGCT (used to be teratoma, teenagers)
148
Give 2 risk factors for a testicular tumour
- ) Undescended testis
- ) Infant hernia
- ) Infertility
149
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
150
What are the 4 stages of testicular tumours?
1) No evidence of mets
2) Infradiaphragmatic node involvement
3) Supradiaphragmatic node involvement
4) Lung involvement
151
How are nodal mets spread in testicular tumours?
Para-aortic nodes
152
What tests do we do to diagnose testicular tumours?
- ) CXR, CT
- ) Excision biopsy
- ) Tumour markers
153
What are the 2 tumour markers in testicular tumours?
Beta-hCG, alpha-FP
154
What does beta-hCG stand for?
Beta human chorionic gonadotropin
155
What does alpha-FP stand for?
Alpha fetoprotein
156
What is the treatment for a testicular tumour?
- ) Radical orchidectomy
- ) Radiotherapy (seminomas very radiosensitive)
- ) Possible semen collection for future
157
What 3 drugs do we use in the chemotherapy for NSGCTs?
- ) Bleomycin
- ) Etoposide
- ) Cisplatin
158
Give 2 associations with prostate cancer
- ) Positive family history
| - ) Increased testosterone
159
What is the most common type of prostate cancer
Adenocarcinoma
160
Where do prostate adenocarcinomas arise?
Peripheral prostate
161
Give 3 ways prostate cancer can spread
- ) Local (seminal vesicles, bladder, rectum)
- ) Lymph
- ) Haematogenously
162
Give 3 symptoms of prostate cancer
- ) Asymptomatic
- ) Nocturia
- ) Hesitancy
- ) Poor stream
- ) Terminal dribbling
- ) Obstruction
- ) Weight loss and bone pain suggest mets
163
What does a PR/DRE exam show in prostate cancer?
Hard, irregular prostate
164
How do we diagnose prostate cancer?
- ) Increased PSA
- ) Transrectal US and biopsy
- ) Bone scan
- ) CT/MRI (MRI to stage)
165
What does PSA do?
Prostate specific antigen liquefies the semen
166
What grading system do we do in prostate cancer?
Gleason grading (add 2 most common grades together)
167
What is the difference between grade and stage in relation to cancers?
Grade - biological aggressiveness
| Stage - extent of disease
168
What is the treatment for prostate cancer?
- ) Radical prostatectomy
- ) Radical radiotherapy
- ) Hormone therapy
- ) Active surveillance
- ) Analgesia
- ) Treat hypercalcaemia
169
What tests are done in the screening for prostate cancer? (3)
DRE, transracial US, PSA
170
Where does renal cell carcinoma arise from? (RCC)
Proximal renal tubular epithelium
171
What is a major risk factor for RCC?
Haemodialysis
172
What does RCC present with?
- ) 50% found incidentally
- ) Haematuria
- ) Loin pain
- ) Abdominal mass
- ) Anorexia, malaise, weight loss
- ) Pyrexia of unknown origin
- ) Varicocele rarely
173
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
174
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
175
What is the Mayo prognostic risk score in RCC?
```
SSIGN
Predicts survival by looking at
-) State
-) Size
-) Grade
-) Necrosis
```
176
What are the 4 stages of RCC?
I - <7cm, kidney
II - >7cm, kidney
III - outside kidney, local spread
IV - outside kidney, metastatic spread
177
Give an anti-angiogenesis agent
Pazopanib, sunitnib, axitinib
178
What are the majority of bladder cancers? (>90%)
Transitional cell carcinomas (TTC)
179
What are the 3 grades of TTCs?
1 - differentiated
2- intermediate
3 - poorly differentiated
180
Give 2 presenting features of bladder tumours
- ) Painless haematuria
- ) Recurrent UTIs
- ) Voiding irritability
181
Give 3 associations with bladder tumours
- ) Smoking
- ) Aromatic amines (rubber)
- ) Chronic cystitis
- ) Schistosomiasis (increased risk of squamous cell carcinoma)
- ) Pelvic irradiation
182
What increases morbidity in bladder cancer?
Penetrating muscle (20%
183
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
```
184
Give some tests we can do for bladder tumours
- ) Cystoscopy with biopsy is diagnostic
- ) Urine MC&S
- ) CT urogram
185
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)
186
How do we treat T2, T3 TCC of the bladder? (3)
- ) Radical cystectomy best
- ) Radiotherapy
- ) Post-op chemo (M-VAC)
187
What is the M-VAC chemotherapy treatment?
Methotrexate
Vinblastine
Doxorubicin
Cisplatin
188
How do we treat T4 TCC of the bladder? (2)
- ) Palliative chemo/radio
| - ) Chronic catheterisation and urinary diversions for pain
189
Where does local spread of TTC go?
Pelvic structures
190
Where does lymphatic spread of TTC go?
Iliac and para-aortic nodes
191
Where does haematogenous spread of TTC go?
Liver and lungs
192
What is acute kidney injury? (AKI)
A syndrome of decreased renal function over hours-days
193
How is AKI measured?
Serum creatinine or urine output
194
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
195
Give 3 risk factors for AKI
- ) CKD
- ) Age
- ) Male
- ) Comorbidity (DM, CVD, malignancy, chronic liver disease, complex surgery)
196
Give 4 causes of AKI
- ) Sepsis
- ) Major surgery
- ) Cardiogenic shock
- ) Other hypovolaemia
- ) Drugs
- ) Hepatorenal syndrome
- ) Obstruction
197
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
198
What tests do we do for AKI?
- ) Drugs history
- ) Urine dipstick
- ) FBC, U&E, LFT, clotting, CK, CRP, ABG
- ) Renal US
199
How do we treat AKI?
- ) Correct pre and post renal factors
- ) Treat hyperkalaemia
- ) Pulmonary oedema with loop diuretics (furosemide)
- ) Daily monitoring
- ) Haemodialysis/haemofiltration
200
How do we treat hyperkalaemia?
Give insulin (drives potassium into cell) and dextrose (don't want hypocalcaemia)
201
What do we give to treat the heart in hyperkalaemia?
Calcium gluconaete
202
What is chronic kidney disease? (CKD)
Abnormal kidney structure or function, present for >3 months, with implications for health
203
What is CKD based on? (3)
- ) GFR category
- ) Presence of albuminuria as a marker of kidney damage
- ) Cause of kidney disease
204
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
205
Give the 3 most common causes of CKD
- ) Diabetes
- ) Glomerulonephritis
- ) Increased BP/renovascular disease
206
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
207
Give 4 symptoms of CKD
- ) Anorexia
- ) SOB
- ) Peripheral oedema
- ) Nausea
- ) Vomiting
- ) Restless legs
- ) Fatigue
- ) Weakness
- ) Pruritus
- ) Bone pain
- ) Amenorrhoea
- ) Impotence
208
In which stage does CKD become symptomatic?
G4
209
Give 3 signs of CKD
- ) Oliguria
- ) Dyspnoea
- ) Increased BP
- ) Cardiomegaly
210
What 2 things are decreased in a blood test in CKD?
- ) Hb (normocytic anaemia)
| - ) Calcium
211
What 2 things are increased in a blood test in CKD?
- ) Phosphate
| - ) PTH
212
What tests do we do for CKD?
- ) Blood
- ) Urine dipstick (Bence Jones)
- ) USS
- ) Renal biopsy
213
What does a US show in CKD?
- ) Small except in infiltrative disorders, APKD, DM
- ) Consider reno vascular disease if asymmetrical
- ) Poor corticomedullary differentiation
214
What can untreated CKD present with?
- ) Severe uraemia
- ) Hyperkalaemia causing arrhythmias
- ) Encephalopathy
- ) Seizures
- ) Coma
215
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
216
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)
217
What is nephrosis?
Proteinuria due to podocyte pathology
218
What is nephritis?
Haematuria due to inflammatory damage
219
What can occur if GN causes scarring?
Proteinuria
220
What is the treatment for GN?
BP control and inhibition of renin-angiotensin axis
221
What is IgA nephropathy?
Commonest primary GN in high income countries
222
What is the presentation of IgA nephropathy?
- ) Asymptomatic NVH
- ) Episodic VH within 12-72h of infection
- ) Increased BP
223
How do we diagnose IgA nephropathy?
Renal biopsy shows IgA deposition in mesangium
224
What is the treatment for IgA nephropathy?
- ) ACEI/ARB reduce proteinuria and protect renal function
| - ) Corticosteroids and fish oil if persistent proteinuria
225
What is the triad of presentation of nephritic syndrome?
- ) Moderate/severe increased BP
- ) Haematuria
- ) Moderate/severe decreased GFR
226
What is the triad of presentation of nephrotic syndrome?
- ) Hypoalbuminaemia
- ) Proteinuria
- ) Oedema
227
Give 2 primary causes of nephritic syndrome
- ) IgA nephropathy
| - ) Mesangiocapillary glomerulonephritis
228
Give 2 secondary causes of nephritic syndrome
- ) Streptococcal infection
- ) Vasculitis
- ) SLE
- ) Cryoglobulinaemia
- ) Anti GBM disease (Goodpasture's)
229
Give 3 primary causes of nephrotic syndrome
- ) Minimal change disease
- ) Membranous nephropathy
- ) Focal segmental glomerulosclerosis (FSGS)
- ) Membranoproliferative GN
230
Give 2 secondary causes of nephrotic syndrome
- ) DM
- ) Lupus nephritis
- ) Myeloma
- ) Amyloid
- ) Pre-eclampsia
231
What is the filtration barrier of the kidney formed by? (3)
- ) Podocytes
- ) Glomerular basement membrane
- ) Endothelial cells
232
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
233
What is the presenting feature of nephrotic syndrome?
Generalised pitting oedema
234
How do we treat nephrotic syndrome? (4)
- ) Reduce oedema - loop diuretics
- ) Treat underlying cause
- ) Reduce proteinuria - ACEI
- ) Treat complications - statins, aspirin
235
Give 2 complications of nephrotic syndrome
- ) Thromboembolism
- ) Infection
- ) Hyperlipidaemia
236
How do we reduce oedema?
- ) Fluid and salt restriction
| - ) Loop diuretics (furosemide)
237
How do we reduce proteinuria?
ACEI/ARB
238
How do we treat a thromboembolism?
Heparin and wararin
239
What is the most common cause of nephrotic syndrome in children?
Minimal change disease
240
Give 3 things membranous nephropathy can be secondary to
- ) Malignancy
- ) Infection
- ) Immunological
- ) Drugs
241
How do we diagnose membranous nephropathy?
Anti-phospholipase A2 receptor antibody in idiopathic disease
242
What does a biopsy show in membranous nephropathy?
Diffusely thickened GBM due to sub epithelial deposits
243
What is the treatment for membranous nephropathy?
- ) ACE/ARB and BP control
| - ) Immunosuppression in high risk of progression
244
Give 3 causes of minimal change disease
- ) Idiopathic (most)
- ) Drugs (NSAIDs, lithium)
- ) Paraneoplastic (Hodgkin's lymphoma)
245
What does electron microscopy show in minimal change disease?
Effacement of podocyte foot processes (no longer tight)
246
How do we treat minimal change disease?
- ) Prenisolone (high relapse rate)
| - ) Cyclophosphamide for frequent relapses
247
What is the commonest GN seen on renal biopsy?
Focal segmental glomerulosclerosis, FSGS
248
Give 3 secondary causes of FSGS
- ) HIV
- ) Heroin
- ) Lithium
- ) Lymphoma
- ) Any cause of decreased kidney mass/nephrons
- ) Kidney scarring
249
Which nephrotic GN doesn't lead to renal failure?
Minimal change disease
250
How do we diagnose FSGS?
Glomeruli have scarring of certain segments (focal sclerosis)
251
How do we treat FSGS? (3)
- ) ACEI/ARB and BP control
- ) Corticosteroids only in idiopathic disease
- ) Plasma exchange and rituximab for recurrence in transplants
252
What is the equation for STI/HIV transmission?
```
R=BCD
R - reproductive rate
B - infectivity rate
C - partners over time
D - duration of infection
```
253
What does chlamydia affect in neonates?
Conjunctiva
254
What is the infecting organism in chlamydia?
Chlamydia trachomatis
255
What are the symptoms in males with chlamydia? (2)
- ) Dysuria
| - ) Urethral discharge
256
What is the % transmission of male to female and female to male in chlamydia?
70%
257
Give 2 complications of males with chlamydia
- ) Epididymo-orchititis
| - ) Reactive arthritis
258
Give 2 symptoms in females with chlamydia
- ) Discharge
- ) Menstrual irregularity
- ) Dysuria
259
In whom is chlamydia more asymptomatic?
Females
260
Give 2 complications of females with chlamydia
- ) Pelvic inflammatory disease
- ) Neonatal transmission
- ) Fitz Hugh Curtis syndrome
261
How do we diagnose chlamydia?
- ) Nucleic acid amplification tests
- ) Vaginal and endocervical swab - women
- ) First void urine - men
262
How do we treat chlamydia? (2)
- ) Azithromycin or doxycycline
| - ) Eryhtomycin or azithromycin in pregnancy
263
Which is the most common STI?
Chlamydia
264
How does gonorrhoea present in males? (2)
- ) Dysuria
| - ) Urethral discharge
265
How does gonorrhoea present in females? (3)
- ) Discharge
- ) Menstrual irregularity
- ) Dysuria
266
Give 2 complications of gonorrhoea in females
- ) Pelvic inflammatory disease
- ) Neonatal transmission
- ) Fitz Hugh Curtis syndrome
267
What does pelvic inflammatory disease include? (3)
- ) Tubal factor infertility
- ) Ectopic pregnancy
- ) Chronic pelvic pain
268
Give a neonatal transmission (STIs)
- ) Ophthalmia neonatorum
| - ) Atypical pneumonia
269
How do we diagnose gonorrhoea?
Same as for chlamydia
270
What is the causative organism in gonorrhoea?
Neisseria gonorrhoeae
271
What STI often occurs in a relationship, and which is associated with recent partner change?
Relationship - chlamydia
| Change - gonorrhoea
272
What can gonorrhoea cause in babies?
Blindness
273
What is the causative organism in syphilis?
Treponema pallidum
274
What are the 3 presentations of syphilis?
- ) Primary (<90d after inoculation)
- ) Secondary (4-10 weeks)
- ) Tertiary (20-40y)
275
What is the presentation of primary syphilis?
-) Macule > papuule > typically painless ulcer (chancre)
276
What is the presentation of secondary syphilis? (4)
- ) Rash
- ) Mucous patches
- ) Condyloma late (raised pale plaques)
- ) Systemic - fever, headache, myalgia, lymphadenopathy, hepatitis
277
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
278
What is the biggest risk group for syphilis?
Men having sex with men
279
How do we diagnose syphilis?
- ) PCR, serology
| - ) T. palladim as antigen
280
How do we treat syphilis?
IM benzylpenicillin
281
What is primary prevention?
Prevent onset of disease
282
What is secondary prevention?
Detect and treat disease early
283
What is tertiary prevention?
Reduce long term effects of disease
284
What is pre-exposure prophylaxis of HIV?
PrEP
285
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
286
How do we treat an acute retention of urine?
Catheterisation
287
Where do the kidneys lie?
Retroperitoneal, T11-L3
288
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
289
What type of control does the pelvic nerve have (P/S) of the bladder and sphincter, and what are its roots?
- ) Parasympathetic
| - ) S2-4
290
What type of control does the hypogastric plexus have (P/S) of the bladder and sphincter, and what are its roots?
- ) Sympathetic
| - ) T11-L2
291
What type of control does the pudendal nerve have (P/S) of the bladder and sphincter, and what are its roots?
- ) Somatic
| - ) S2-4
292
What type of nerve is the afferent pelvic nerve, and where is it from?
- ) Sensory nerve
| - ) From detrusor muscle
293
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
294
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
295
What role does the cortex have in the control of the bladder and sphincter?
Voluntary control
296
What role does the pontine micturition centre/PAG have in the control of the bladder and sphincter?
Coordination of voiding
297
What role does the sacral micturition centre have in the control of the bladder and sphincter?
Micturition reflex
298
What role does Onuf's nucleus have in the control of the bladder and sphincter?
Guarding reflex
299
Why does the pressure in the bladder remain low as the volume increases?
Receptive relaxation and detrusor muscle compliance
300
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
301
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
302
What is the guarding reflex?
Voluntary control of micturition in anatomically an functionally normal adults when it is inappropriate to void
303
Give the 3 determinants of fluid movement
- ) Hydrostatic pressure
- ) Osmotic presure
- ) Oncotic pressure
304
What is hypo/hypervolaemia?
Too little/too much fluid
305
What is the pulse like in hypovolaemia?
Tachycardic
306
What occurs to creatinine and haemoglobin in hypo/hypervolaemia?
Hypo - increased
| Hyper - decreased
307
Give 3 sites of fluid accumulation
- ) Pulmonary oedema
- ) Pleural effusion
- ) Ascites
- ) Intraabdominal collection/bleeds
308
Give 2 risk factors for hypovolaemia
- ) Elderly
- ) Ileostomy/colostomy
- ) Short bowel syndrome
- ) Bowel obstruction
- ) Diuretics
309
Give 2 risk factors for hypervolaemia
- ) AKI
- ) CKD
- ) HF
- ) Liver failure
310
How do we treat hypovolaemia? (3)
- ) Fluid
- ) Treat cause
- ) Crystalloid or colloid fluid
311
How do we treat hypervolaemia? (3)
- ) Fluid restriction
- ) Treat cause
- ) Diuretics
312
What should not be prescribed in kidney failure patients, and why?
Hartmann's solution, contains potassium
313
Where do loop diuretics work?
Loop of Henle
314
Where do thiazide diuretics work?
Distal tubule
315
Where do aldosterone antagonists work?
Collecting duct
316
Give an example of an aldosterone antagonist
- ) Spironolactone
| - ) Potassium sparing diuretic
317
What drugs block aquaporins?
Vasopressin antagonists
318
What can renal artery stenosis lead to?
Severe hypertension (kidney thinks BP is too low)
319
What do NSAIDs reduce the amount of?
Prostaglandin
320
What does prostaglandin do to the glomerulus?
Preferentially dilates the afferent arteriole
321
What does angiotensin II do to the glomerulus?
Preferentially constricts the efferent arteriole
322
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
323
You got this?
Ofc
324
What protein is found on a dipstick in CKD?
Bence Jones
325
What is the mutation in ARPKD?
PKHD1
