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Medicine Year 2 5 > Urogenital and renal > Flashcards

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
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2
Q

Give 2 signs of testicular torsion

A
  • ) Inflammation of one tests - tender, hot, swollen

- ) Testis may lay high and transversely

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3
Q

Between what ages is testicular torsion more common?

A

11-30

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4
Q

What is the main differential diagnoses of testicular torsion?

A

Epididymo-orchitis

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5
Q

What do we do to diagnose testicular torsion?

A

Doppler US may demonstrate lack of blood flow to testes

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6
Q

What is our immediate thought when someone presents with a suspected testicular torsion?

A

Immediate surgery

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7
Q

What is the treatment for testicular torsion?

A

Possible orchidectomy and bilateral fixation - expose and untwist, fix to scrotum

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8
Q

What is a hydrocele?

A

Fluid within the tunica vaginalis

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9
Q

What is primary hydrocele associated with?

A

Processus vaginalis (typically resolves in 1st year)

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10
Q

Give 2 causes of a secondary hydrocele

A
  • ) Tumour
  • ) Trauma
  • ) Infection
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11
Q

Which type of hydrocele is more common and larger?

A

Primary

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12
Q

How do we treat hydroceles?

A

Aspiration or surgery

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13
Q

What is a varicocele?

A

Dilated veins of the pam-uniform plexus

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14
Q

Which side is more commonly affected by varicoceles?

A

Left

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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

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16
Q

What are varicoceles associated with?

A

Subfertility

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17
Q

How do we repair varicoceles?

A

Surgery or embolisation

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18
Q

What are epididymal cysts?

A

Contain clear/milky (spermatocele) fluid

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19
Q

When do epididymal cysts usually develop?

A

Adulthood

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20
Q

Where do epididymal cysts usually occur?

A

Above and behind testes

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21
Q

How do we treat symptomatic epididymal cysts?

A

Remove

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22
Q

What is epididymo-orchitis?

A

Inflammation of the epididymis and testes

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23
Q

What is epididymitis?

A

Inflammation of the epididymis

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24
Q

Give 3 causes of epididymo-orchitis

A
  • ) Chlamydia
  • ) E. coli
  • ) Mumps
  • ) N. gonorrhoea
  • ) TB
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25
Q

Give 3 symptoms of epididymo-orchitis

A
  • ) Sudden-onset tender swelling
  • ) Dysuria
  • ) Sweats/fever
  • ) UTI/STI symptoms
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26
Q

How do we treat epididymo-orchitis? (4)

A
  • ) Antibiotics
  • ) Analgesia
  • ) Scrotal support
  • ) Drainage of any abscess
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27
Q

What antibiotics do we give in epididymo-orchitis? (3)

A
  • ) <35 doxycycline
  • ) Ceftriaxone if gonorrhoea
  • ) >35 (non STI) ciprofloxacin/ofloxacin
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28
Q

How may the organism infect in epididymo-orchitis?

A
  • ) Retrograde spread from prostatic urethra and seminal vesicles
  • ) Bloodstream (less common)
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29
Q

How do we diagnose epididymis-orchitis?

A

MSU and STI screen

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30
Q

If we cannot get above a scrotal mass, what is it?

A

Inguinoscrotal hernia or hydrocele extending proximally

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31
Q

If a scrotal mass is separate and cystic, what is it?

A

Epididymal cyst

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32
Q

If a scrotal mass is separate and solid, what is it?

A

Epididymitis/varicocele

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33
Q

If a scrotal mass is testicular and cystic, what is it?

A

Hydrocele

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34
Q

If a scrotal mass is testicular and solid, what is it?

A

Tumour, haematocele, granuloma, orchitis, gumma

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35
Q

What is a haematocele?

A

Blood in tunica vaginalis

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36
Q

What does a haematocele follow?

A

Trauma

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37
Q

How do we treat a haematocele?

A

Drainage/excision

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38
Q

What is the pathology of benign prostatic hyperplasia? (BPH)

A
  • ) 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)
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39
Q

Give 4 symptoms of BPH

A

LUTS

  • ) Nocturia
  • ) Frequency
  • ) Urgency
  • ) Post-micturition dribbling
  • ) Poor stream/flow
  • ) Hesitancy
  • ) Overflow incontinence
  • ) Haematuria
  • ) Bladder stones
  • ) UTI
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40
Q

How do we test for BPH?

A
  • ) PR exam
  • ) MSU
  • ) U&E
  • ) US
  • ) PSA
  • ) Biopsy
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41
Q

What are the treatments for BPH? (3

A

0-) Lifestyle (caffeine, alcohol, voiding techniques, train bladder)

  • ) Drugs (alpha-blockers tamsulosin; 5-alpha-reductase inhibitors, finasteride)
  • ) Surgery
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42
Q

How do alpha-blockers work in the treatment of BPH?

A

Decrease smooth muscle tone of prostate and bladder

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43
Q

How do 5-alpha-reductase inhibitors work in the treatment of BPH?

A

Reduce conversion of testosterone to the more potent androgen dehydrogenase

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44
Q

What should patients use when using 5-alpha-reductase inhibitors?

A

Condoms - excreted in semen

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45
Q

What are our surgical options for BPH?

A
  • ) Transurethral resection of prostate (TURP)
  • ) Transurethral incision of prostate (TUIP)
  • ) Retropubic prostatectomy
  • ) Transurethral laser induced prostatectomy (TULIP)
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46
Q

What is the major cause of incontinence in men?

A

Enlargement of the prostate

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47
Q

What surgery in men may cause incontinence?

A

TURP

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48
Q

What is functional incontinence?

A

Too slow in finding the toilet due to immobility or unfamiliar surroundings

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49
Q

What is stress incontinence?

A

Leakage from an incompetent sphincter (e.g in coughing, laughing, pregnancy, after birth)

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50
Q

Give 2 risk factors for stress incontinence

A
  • ) Age

- ) Obesity

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51
Q

How do we test for stress incontinence?

A
  • ) 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
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52
Q

What is urge incontinence/overactive bladder?

A

The urge to urinate quickly followed by uncontrollable and sometimes complete emptying of the bladder as the detrusor muscle contracts

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53
Q

Give 3 things that can precipitate urgency/leaking

A
  • ) Arriving home
  • ) Cold
  • ) Sound of running water
  • ) Caffeine
  • ) Obesity
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54
Q

What is the cause for urge incontinence/overactive bladder?

A

Detrusor overactivity

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55
Q

Give 3 treatments for detrusor overactivity

A
  • ) Antimuscarinics
  • ) Topical oestrogens
  • ) Beta 3 adrenergic agonist
  • ) Intravesical botulinum toxin
  • ) Surgery
  • ) Bladder training
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56
Q

Give 2 other causes for urge incontinence/overactive bladder

A
  • ) Urinary infection
  • ) Diabetes
  • ) Diuretics
  • ) Atrophic vaginitis
  • ) Urethritis
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57
Q

What is continuous incontinence due to?

A

Due to fistula (between vagina and bladder)

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58
Q

In who does social incontinence occur?

A

Dementia, confusion, sedation

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59
Q

How do we treat stress incontinence?

A
  • ) Pelvic floor exercises
  • ) Intravaginal electrical stimulation
  • ) Surgery
  • ) Duloxetine
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60
Q

How do we treat urge incontinence?

A
  • ) Examine for spinal cord and CNS signs, vaginitis
  • ) Bladder training
  • ) Weight loss
  • ) Aids, absorbant pads
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61
Q

How can we treat vaginitis?

A

Topical oestrogen therapy

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62
Q

What is bacteriuria?

A

Bacteria in the urine (symptomatic/asymptomatic)

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63
Q

Give 2 lower UTIs

A
  • ) Cystitis (bladder)

- ) Prostatitis (prostate)

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64
Q

Give an upper UTI

A

Pyelonephritis (kidney/renal pelvis)

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65
Q

What is bacterial cystitis/urethral syndrome?

A

A diagnosis of exclusion in patients with dysuria and frequency

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66
Q

What is the classification of a UTI? (2)

A

Complicated - structural/functional abnormality of the GU tract (obstruction, catheter, stones etc)
Uncomplicated - normal renal tract structure and function

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67
Q

Give 3 risk factors for developing a UTI

A
  • ) Increased bacterial inoculation
  • ) Increased binding of uropathogenic bacteria (spermicide use, decrease oedstrogen, menopause)
  • ) Decreased urine flow
  • ) Increased bacterial growth
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68
Q

Give 2 causes for bacterial inoculation in a UTI

A
  • ) Sexual activity
  • ) Urinary incontinence
  • ) Faecal incontinence
  • ) Constipation
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69
Q

Give 2 causes of increased binding of uropathogenic bacteria in a UTI

A
  • ) Spermicide use
  • ) Decreased oestrogen
  • ) Menopause
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70
Q

Give a cause of a decreased urine flow in a UTI

A
  • ) Dehydration

- ) Obstructed tract

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71
Q

Give 3 causes of increased bacterial growth in a UTI

A
  • ) DM
  • ) Immunosuppression
  • ) Obstruction
  • ) Stones
  • ) Catheter
  • ) Renal tract malformation
  • ) Pregnancy
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72
Q

What is the main causative organism of UTIs?

A

E. coli

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73
Q

Give 4 symptoms of cystitis

A
  • ) Frequency
  • ) Dysuria
  • ) Urgency
  • ) Suprapubic pain
  • ) Polyuria
  • ) Haematuria
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74
Q

Give 4 symptoms of acute pyelonephritis

A
  • ) Fever
  • ) Rigor
  • ) Vomiting
  • ) Loin pain/tenderness
  • ) Costovertebral pain
  • ) Associated cystitis symptoms
  • ) Septic shock
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75
Q

Give 4 symptoms of prostatitis

A
  • ) Pain (perineum, rectum, scrotum, penis, bladder, lower back)
  • ) Fever
  • ) Malaise
  • ) Nausea
  • ) Urinary symptoms
  • ) Swollen/tender prostate on PR
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76
Q

Give 2 signs of a UTI

A
  • ) Fever

- ) Abdominal/loin tenderness

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77
Q

In who should we not rely on classical symptoms to diagnose a UTI?

A

Catheterised patients

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78
Q

When should we treat a UTI empirically?

A

Non pregnant women with 3 or more symptoms of cystitis and no vaginal discharge

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79
Q

Give 4 tests for a UTI

A
  • ) Dipstick
  • ) MSU culture
  • ) Blood tests
  • ) Imaging (USS)
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80
Q

What is the empirical treatment for a presumed E. coli infection?

A

Trimethoprium or nitrofuratoin

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81
Q

What antibiotic do we avoid in the 1st trimester?

A

Trimethoprim

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82
Q

What antibiotic do we avoid in the 3rd trimester?

A

Nitrofuratoin

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83
Q

What antibiotic do we treat an UUTI with?

A

Co-amoxiclv

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84
Q

What do erections result from?

A

Neuronal release of nitric oxide which, via cyclic GMP and Ca, hyperpolarises and thus relaxes vascular and trabecular smooth muscle cells, allowing engorgement

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85
Q

What is the nerve supply of the penis in an erection? (2)

A

POINT AND SHOOT
Parasympathetic S2-4 for erection
Sympathetic T11-L2 for ejaculation

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86
Q

Give the 3 main causes of erectile dysfunction (ED)

A
  • ) Smoking
  • ) Alcohol
  • ) Diabetes
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87
Q

Give 4 other causes of ED

A
  • ) Obesity
  • ) Hyperthyroidism
  • ) Hypogonadism
  • ) MS
  • ) Cord lesions
  • ) Neuropathy
  • ) Pelvic surgery
  • ) Radiotherapy
  • ) Prostatic hyperplasia
  • ) Drugs
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88
Q

Give 2 drugs that can cause ED

A
  • ) Digoxin
  • ) Beta blockers
  • ) Diuretics
  • ) Antipsychotics
  • ) Antidepressants
  • ) Oestrogen’s
  • ) Narcotics
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89
Q

What tests do we do in ED?

A
  • ) Sexual and psychosocial history
  • ) U&E, LFT, glucose, TFT, LH, FSH, lipids, testosteron, prolactin
  • ) Doppler
  • ) BP
  • ) Genital examination
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90
Q

What is ED?

A

The persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance

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91
Q

What is the treatment for ED? (4)

A
  • ) Treat causes
  • ) Counselling
  • ) Oral phosphodiesterase (PDE5) inhibitors (sildenafil, tadalafil)
  • ) Vacuum aids, intracavernosal injections, transurethral pellets, prostheses
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92
Q

How do phosphodiesterase inhibitors work?

A

Increase cGMP

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93
Q

What is priapism?

A

Erection that lasts for longer than 4 hours

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94
Q

How do we treat priapism?

A

Aspirate corpora

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95
Q

What does ADPKD stand for?

A

Autosomal dominant polycystic kidney disease

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96
Q

Give 2 mutations that cause ADPKD, and when they will reach ESRF

A

PKD1, 50s

PKD2, 70s

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97
Q

What does ESRF stand for?

A

End stage renal failure

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98
Q

Give 3 renal symptoms of ADPKD

A
  • ) Loin pain
  • ) Visible haematuria
  • ) Cyst infection
  • ) Renal calculi
  • ) High BP
  • ) Progressive renal failure
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99
Q

Give 3 extrarenal symptoms of ADPKD

A
  • ) Liver cysts
  • ) Intracranial aneurysm > SAH
  • ) Mitral valve prolapse
  • ) Ovarian cyst
  • ) Diverticular disease
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100
Q

How do we diagnose ADPKD?

A

USS to look for renal/liver cysts

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101
Q

What is the treatment for ADPKD? (5)

A
  • ) Limit water intake
  • ) Treat BP (not CCB)
  • ) Treat infections
  • ) Possible cyst decompression for pain
  • ) Possible transplant
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102
Q

What do renal stones consist of?

A

Crystal aggregates

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103
Q

What are renal stones also known as?

A

Calculi, nephrolithiasis

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104
Q

Where are the 3 classic areas for renal stones to be deposited?

A

-) Pelviureteric junction
-) Pelvic brim
-) Vesicoureteric junction
LEARN THIS

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105
Q

In which gender do renal stones occur more commonly in?

A

Male

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106
Q

What are renal stones made of?

A
  • ) Calcium oxalate (75%)
  • ) Magnesium ammonium phosphate (15%)
  • ) Hydroxyapatite (5%)
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107
Q

Give 4 main symptoms of renal stones

A
  • ) Pain - renal colic with N&V, obstruction symptoms
  • ) Infection - fever, rigors, loin pain, nausea, vomiting
  • ) Haematuria
  • ) Proteinuria
  • ) Sterile pyuria
  • ) Anuria
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108
Q

What tests do we do for renal stones?

A
  • ) FBC, U&E, Ca, PO4, glucose, bicarbonate, urate
  • ) Urine dipstick
  • ) MSU
  • ) Non-contrast CT (or KUB XR
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109
Q

What does KUB XR stand for?

A

Kidney ureters bladder XR

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110
Q

What is the initial treatment for renal stones?

A
  • ) Analgesia
  • ) Fluids
  • ) Antibiotics if infection
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111
Q

What is the treatment for stones <5mm in the lower ureter?

A

90-95% pass spontaneously, increase fluid

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112
Q

What is the treatment for stones >5mm/pain not resolving?

A
  • ) Medical expulsive therapy (nifedipine or alpha blockers)
  • ) Then extracorporeal shockwave lithotripsy (ESWL)
  • ) Or ureteroscopy using a basket
  • ) Percutaneous nephrolithotomy
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113
Q

Give an example of an alpha blocker

A

Tamsulosin

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114
Q

Give 2 ways we can prevent renal stones

A
  • ) Drink plenty
  • ) Normal dietary Ca intake (dairy)
  • ) Reduce BMI, exercise
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115
Q

Give 3 classifications of a urinary tract obstruction (UTO)

A
  • ) Partial, complete
  • ) Unilateral, bilateral
  • ) Luminal, mural, extra-mural
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116
Q

Give 2 examples of a luminal UTO

A
  • ) Stones
  • ) Tumour
  • ) Blood clot
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117
Q

Give 2 examples of a mural UTO

A
  • ) Stricture

- ) Neuromuscular dysfunction

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118
Q

Give 2 examples of an extra-mural UTO

A
  • ) Abdominal/pelvic mass/tumour
  • ) Retroperitoneal fibrosis
  • ) Surgery
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119
Q

What 2 types of UTO require urgent treatment?

A
  • ) Bilateral obstruction

- ) Obstruction with infection

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120
Q

What is hydronephrosis?

A

Presence of water in the kidneys due to obstruction

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121
Q

What is the equation for renal blood flow? (RBF)

A

RBF = (aortic pressure - renal venous pressure) / renal vascular resistance

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122
Q

Give a clinical feature of an acute UUTO

A
  • ) Loin to groin pain

- ) May be superimposed infection, tenderness, enlarged kidney

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123
Q

Give 2 clinical features of a chronic UUTO

A
  • ) Flank pain
  • ) Renal failure
  • ) Superimposed infection
  • ) Polyuria
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124
Q

Give 2 clinical features of an acute LUTO

A
  • ) Severe supra public pain
  • ) +/- Acute confusion
  • ) Often acute on chronic
  • ) Distended, palpable bladder dull to percussion
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125
Q

Give 3 causes of an acute LUTO

A
  • ) Prostatic obstruction
  • ) Urethral strictures
  • ) Anticholinergics
  • ) Blood clots
  • ) Alcohol
  • ) Constipation
  • ) Post op
  • ) Infection
  • ) Neurological
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126
Q

Give 2 clinical features of an chronic LUTO

A
  • ) Frequency
  • ) Hesitancy
  • ) Poor stream
  • ) Terminal dribbling
  • ) Overflow incontinence
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127
Q

Give 2 signs of a chronic LUTO

A
  • ) Distened, palapable bladder

- ) +/- Large prostate on PR

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128
Q

Give 3 causes of a chronic LUTO

A
  • ) Prostatic enlargement
  • ) Pelvic malignancy
  • ) Rectal surgery
  • ) DM
  • ) CNS disease
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129
Q

Give 2 complications of a chronic LUTO

A
  • ) UTI
  • ) Urinary retention
  • ) Renal failure
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130
Q

Give 3 tests for a UTO

A
  • ) U&E, creatinine, FBC, PSA
  • ) Urine dipstick
  • ) US
  • ) Radionuclide imaging for functional assessment
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131
Q

What is the treatment for an UUTO?

A
  • ) Nephrostomy/ureteric stent

- ) Pyeloplasty to widen PUJ

132
Q

What is the treatment for a LUTO?

A
  • ) Urethral or suprapubic catheter
  • ) Only catheterise in chronic if pain, infection, renal impairment
  • ) Treat cause
133
Q

What reduces stent related pain?

A

Alpha blockers

134
Q

What is the pain like in renal colic?

A
  • ) Loin to groin pain

- ) Intermittent colicky

135
Q

What does the patient look like in renal colic?

A

Patient writhing

136
Q

Where may the pain radiate to in renal colic?

A

Scrotum, labia, tip of penis

137
Q

What occurs with renal colic?

A

Nausea, vomiting, sweating, haematuria

138
Q

What is haematuria?

A

Blood in the urine

139
Q

What is haematuria classified as?

A
  • ) Visible (VH)

- ) Non visible (NVH)

140
Q

Give 3 causes of haematuria

A
  • ) Malignancy
  • ) Calculi/stones
  • ) IgA neuropathy
  • ) Glomerulonephritis
  • ) PKD
141
Q

What is the management of haematuria?

A

-) Urological assessment, imaging, cytoscopy

142
Q

What warrants repeat referral and investigation of haematuria? (2)

A
  • ) Increasing proteinuria

- ) Deteriorating eGFR

143
Q

Give 3 circumstances where we would refer someone to the suspected cancer pathway for bladder cancer

A
  • ) >45 and unexplained VH
  • ) VH that persists/recurs after successful treatment of UTI
  • ) >60 with NVH and dysuria/raised WCC
144
Q

What is the commonest malignancy in men aged 15-44?

A

Testicular tumours

145
Q

Give 3 types of testicular tumour

A
  • ) Seminoma (55%)
  • ) Non-seminomatous germ cell tumour (NSGCT, 33%)
  • ) Mixed germ cell tumour (12%)
  • ) Lymphoma
146
Q

Which testicular tumour occurs more in older people?

A

Seminoma (senile)

147
Q

Which testicular tumour occurs more in younger people?

A

NSGCT (used to be teratoma, teenagers)

148
Q

Give 2 risk factors for a testicular tumour

A
  • ) Undescended testis
  • ) Infant hernia
  • ) Infertility
149
Q

Give 4 signs of a testicular tumour

A
  • ) Painless testis lump found after trauma/infection
  • ) Haemospermia
  • ) Secondary hydrocele
  • ) Pain
  • ) Dyspnoea (lung mets)
  • ) Abdominal mass
  • ) Effects of secreted hormones
150
Q

What are the 4 stages of testicular tumours?

A

1) No evidence of mets
2) Infradiaphragmatic node involvement
3) Supradiaphragmatic node involvement
4) Lung involvement

151
Q

How are nodal mets spread in testicular tumours?

A

Para-aortic nodes

152
Q

What tests do we do to diagnose testicular tumours?

A
  • ) CXR, CT
  • ) Excision biopsy
  • ) Tumour markers
153
Q

What are the 2 tumour markers in testicular tumours?

A

Beta-hCG, alpha-FP

154
Q

What does beta-hCG stand for?

A

Beta human chorionic gonadotropin

155
Q

What does alpha-FP stand for?

A

Alpha fetoprotein

156
Q

What is the treatment for a testicular tumour?

A
  • ) Radical orchidectomy
  • ) Radiotherapy (seminomas very radiosensitive)
  • ) Possible semen collection for future
157
Q

What 3 drugs do we use in the chemotherapy for NSGCTs?

A
  • ) Bleomycin
  • ) Etoposide
  • ) Cisplatin
158
Q

Give 2 associations with prostate cancer

A
  • ) Positive family history

- ) Increased testosterone

159
Q

What is the most common type of prostate cancer

A

Adenocarcinoma

160
Q

Where do prostate adenocarcinomas arise?

A

Peripheral prostate

161
Q

Give 3 ways prostate cancer can spread

A
  • ) Local (seminal vesicles, bladder, rectum)
  • ) Lymph
  • ) Haematogenously
162
Q

Give 3 symptoms of prostate cancer

A
  • ) Asymptomatic
  • ) Nocturia
  • ) Hesitancy
  • ) Poor stream
  • ) Terminal dribbling
  • ) Obstruction
  • ) Weight loss and bone pain suggest mets
163
Q

What does a PR/DRE exam show in prostate cancer?

A

Hard, irregular prostate

164
Q

How do we diagnose prostate cancer?

A
  • ) Increased PSA
  • ) Transrectal US and biopsy
  • ) Bone scan
  • ) CT/MRI (MRI to stage)
165
Q

What does PSA do?

A

Prostate specific antigen liquefies the semen

166
Q

What grading system do we do in prostate cancer?

A

Gleason grading (add 2 most common grades together)

167
Q

What is the difference between grade and stage in relation to cancers?

A

Grade - biological aggressiveness

Stage - extent of disease

168
Q

What is the treatment for prostate cancer?

A
  • ) Radical prostatectomy
  • ) Radical radiotherapy
  • ) Hormone therapy
  • ) Active surveillance
  • ) Analgesia
  • ) Treat hypercalcaemia
169
Q

What tests are done in the screening for prostate cancer? (3)

A

DRE, transracial US, PSA

170
Q

Where does renal cell carcinoma arise from? (RCC)

A

Proximal renal tubular epithelium

171
Q

What is a major risk factor for RCC?

A

Haemodialysis

172
Q

What does RCC present with?

A
  • ) 50% found incidentally
  • ) Haematuria
  • ) Loin pain
  • ) Abdominal mass
  • ) Anorexia, malaise, weight loss
  • ) Pyrexia of unknown origin
  • ) Varicocele rarely
173
Q

What are the tests for RCC? (5)

A
  • ) BP increased from renin secretion
  • ) FBC shows polycythaemia from EPO secretion
  • ) ESR, U&E, ALP
  • ) Urine RBCs, cytology
  • ) US, CT/MRI, CXR
174
Q

What is the treatment for RCC? (4)

A
  • ) 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
Q

What is the Mayo prognostic risk score in RCC?

A 
SSIGN
Predicts survival by looking at
-) State
-) Size
-) Grade
-) Necrosis
176
Q

What are the 4 stages of RCC?

A

I - <7cm, kidney
II - >7cm, kidney
III - outside kidney, local spread
IV - outside kidney, metastatic spread

177
Q

Give an anti-angiogenesis agent

A

Pazopanib, sunitnib, axitinib

178
Q

What are the majority of bladder cancers? (>90%)

A

Transitional cell carcinomas (TTC)

179
Q

What are the 3 grades of TTCs?

A

1 - differentiated
2- intermediate
3 - poorly differentiated

180
Q

Give 2 presenting features of bladder tumours

A
  • ) Painless haematuria
  • ) Recurrent UTIs
  • ) Voiding irritability
181
Q

Give 3 associations with bladder tumours

A
  • ) Smoking
  • ) Aromatic amines (rubber)
  • ) Chronic cystitis
  • ) Schistosomiasis (increased risk of squamous cell carcinoma)
  • ) Pelvic irradiation
182
Q

What increases morbidity in bladder cancer?

A

Penetrating muscle (20%

183
Q

What are the stages of bladder cancer? (T6)

A 
Tis - carcinoma in situ
Ta - epithelium only
T1 - submucosa/lamina propria
T2 - muscle
T3 - perivesical fat
T4 - adjacent organs
184
Q

Give some tests we can do for bladder tumours

A
  • ) Cystoscopy with biopsy is diagnostic
  • ) Urine MC&S
  • ) CT urogram
185
Q

How do we treat Tis/Ta/T1 TCC of the bladder? (2)

A
  • ) Diathermy (heat/electricity) via transurethral cytoscopy/transuretheral resection of bladder tumour
  • ) Consider intravesical BCG (stimulates non-specific immune response)
186
Q

How do we treat T2, T3 TCC of the bladder? (3)

A
  • ) Radical cystectomy best
  • ) Radiotherapy
  • ) Post-op chemo (M-VAC)
187
Q

What is the M-VAC chemotherapy treatment?

A

Methotrexate
Vinblastine
Doxorubicin
Cisplatin

188
Q

How do we treat T4 TCC of the bladder? (2)

A
  • ) Palliative chemo/radio

- ) Chronic catheterisation and urinary diversions for pain

189
Q

Where does local spread of TTC go?

A

Pelvic structures

190
Q

Where does lymphatic spread of TTC go?

A

Iliac and para-aortic nodes

191
Q

Where does haematogenous spread of TTC go?

A

Liver and lungs

192
Q

What is acute kidney injury? (AKI)

A

A syndrome of decreased renal function over hours-days

193
Q

How is AKI measured?

A

Serum creatinine or urine output

194
Q

Give the 3 diagnostic definitions of AKI

A
  • ) 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
Q

Give 3 risk factors for AKI

A
  • ) CKD
  • ) Age
  • ) Male
  • ) Comorbidity (DM, CVD, malignancy, chronic liver disease, complex surgery)
196
Q

Give 4 causes of AKI

A
  • ) Sepsis
  • ) Major surgery
  • ) Cardiogenic shock
  • ) Other hypovolaemia
  • ) Drugs
  • ) Hepatorenal syndrome
  • ) Obstruction
197
Q

What are the 3 aetiology categories of AKI, and give a cause for each

A
  • ) Pre-renal, decreased perfusion to kidney
  • ) Renal, intrinsic renal disease
  • ) Post-renal, obstruction to urine
198
Q

What tests do we do for AKI?

A
  • ) Drugs history
  • ) Urine dipstick
  • ) FBC, U&E, LFT, clotting, CK, CRP, ABG
  • ) Renal US
199
Q

How do we treat AKI?

A
  • ) Correct pre and post renal factors
  • ) Treat hyperkalaemia
  • ) Pulmonary oedema with loop diuretics (furosemide)
  • ) Daily monitoring
  • ) Haemodialysis/haemofiltration
200
Q

How do we treat hyperkalaemia?

A

Give insulin (drives potassium into cell) and dextrose (don’t want hypocalcaemia)

201
Q

What do we give to treat the heart in hyperkalaemia?

A

Calcium gluconaete

202
Q

What is chronic kidney disease? (CKD)

A

Abnormal kidney structure or function, present for >3 months, with implications for health

203
Q

What is CKD based on? (3)

A
  • ) GFR category
  • ) Presence of albuminuria as a marker of kidney damage
  • ) Cause of kidney disease
204
Q

What are the stages of CKD, based on GFR? (6)

A

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
Q

Give the 3 most common causes of CKD

A
  • ) Diabetes
  • ) Glomerulonephritis
  • ) Increased BP/renovascular disease
206
Q

What are decreased GFR and albuminuria independently associated with a higher risk of?

A
  • ) All cause mortality
  • ) Cardiovascular and mortality
  • ) Progressive kidney disease and kidney failure
  • ) AKI
207
Q

Give 4 symptoms of CKD

A
  • ) Anorexia
  • ) SOB
  • ) Peripheral oedema
  • ) Nausea
  • ) Vomiting
  • ) Restless legs
  • ) Fatigue
  • ) Weakness
  • ) Pruritus
  • ) Bone pain
  • ) Amenorrhoea
  • ) Impotence
208
Q

In which stage does CKD become symptomatic?

A

G4

209
Q

Give 3 signs of CKD

A
  • ) Oliguria
  • ) Dyspnoea
  • ) Increased BP
  • ) Cardiomegaly
210
Q

What 2 things are decreased in a blood test in CKD?

A
  • ) Hb (normocytic anaemia)

- ) Calcium

211
Q

What 2 things are increased in a blood test in CKD?

A
  • ) Phosphate

- ) PTH

212
Q

What tests do we do for CKD?

A
  • ) Blood
  • ) Urine dipstick (Bence Jones)
  • ) USS
  • ) Renal biopsy
213
Q

What does a US show in CKD?

A
  • ) Small except in infiltrative disorders, APKD, DM
  • ) Consider reno vascular disease if asymmetrical
  • ) Poor corticomedullary differentiation
214
Q

What can untreated CKD present with?

A
  • ) Severe uraemia
  • ) Hyperkalaemia causing arrhythmias
  • ) Encephalopathy
  • ) Seizures
  • ) Coma
215
Q

What is the treatment of CKD? (7)

A
  • ) 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
Q

What is glomerulonephritis? (GN) (5)

A

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
Q

What is nephrosis?

A

Proteinuria due to podocyte pathology

218
Q

What is nephritis?

A

Haematuria due to inflammatory damage

219
Q

What can occur if GN causes scarring?

A

Proteinuria

220
Q

What is the treatment for GN?

A

BP control and inhibition of renin-angiotensin axis

221
Q

What is IgA nephropathy?

A

Commonest primary GN in high income countries

222
Q

What is the presentation of IgA nephropathy?

A
  • ) Asymptomatic NVH
  • ) Episodic VH within 12-72h of infection
  • ) Increased BP
223
Q

How do we diagnose IgA nephropathy?

A

Renal biopsy shows IgA deposition in mesangium

224
Q

What is the treatment for IgA nephropathy?

A
  • ) ACEI/ARB reduce proteinuria and protect renal function

- ) Corticosteroids and fish oil if persistent proteinuria

225
Q

What is the triad of presentation of nephritic syndrome?

A
  • ) Moderate/severe increased BP
  • ) Haematuria
  • ) Moderate/severe decreased GFR
226
Q

What is the triad of presentation of nephrotic syndrome?

A
  • ) Hypoalbuminaemia
  • ) Proteinuria
  • ) Oedema
227
Q

Give 2 primary causes of nephritic syndrome

A
  • ) IgA nephropathy

- ) Mesangiocapillary glomerulonephritis

228
Q

Give 2 secondary causes of nephritic syndrome

A
  • ) Streptococcal infection
  • ) Vasculitis
  • ) SLE
  • ) Cryoglobulinaemia
  • ) Anti GBM disease (Goodpasture’s)
229
Q

Give 3 primary causes of nephrotic syndrome

A
  • ) Minimal change disease
  • ) Membranous nephropathy
  • ) Focal segmental glomerulosclerosis (FSGS)
  • ) Membranoproliferative GN
230
Q

Give 2 secondary causes of nephrotic syndrome

A
  • ) DM
  • ) Lupus nephritis
  • ) Myeloma
  • ) Amyloid
  • ) Pre-eclampsia
231
Q

What is the filtration barrier of the kidney formed by? (3)

A
  • ) Podocytes
  • ) Glomerular basement membrane
  • ) Endothelial cells
232
Q

What is the pathophysiology of nephrotic syndrome?

A

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
Q

What is the presenting feature of nephrotic syndrome?

A

Generalised pitting oedema

234
Q

How do we treat nephrotic syndrome? (4)

A
  • ) Reduce oedema - loop diuretics
  • ) Treat underlying cause
  • ) Reduce proteinuria - ACEI
  • ) Treat complications - statins, aspirin
235
Q

Give 2 complications of nephrotic syndrome

A
  • ) Thromboembolism
  • ) Infection
  • ) Hyperlipidaemia
236
Q

How do we reduce oedema?

A
  • ) Fluid and salt restriction

- ) Loop diuretics (furosemide)

237
Q

How do we reduce proteinuria?

A

ACEI/ARB

238
Q

How do we treat a thromboembolism?

A

Heparin and wararin

239
Q

What is the most common cause of nephrotic syndrome in children?

A

Minimal change disease

240
Q

Give 3 things membranous nephropathy can be secondary to

A
  • ) Malignancy
  • ) Infection
  • ) Immunological
  • ) Drugs
241
Q

How do we diagnose membranous nephropathy?

A

Anti-phospholipase A2 receptor antibody in idiopathic disease

242
Q

What does a biopsy show in membranous nephropathy?

A

Diffusely thickened GBM due to sub epithelial deposits

243
Q

What is the treatment for membranous nephropathy?

A
  • ) ACE/ARB and BP control

- ) Immunosuppression in high risk of progression

244
Q

Give 3 causes of minimal change disease

A
  • ) Idiopathic (most)
  • ) Drugs (NSAIDs, lithium)
  • ) Paraneoplastic (Hodgkin’s lymphoma)
245
Q

What does electron microscopy show in minimal change disease?

A

Effacement of podocyte foot processes (no longer tight)

246
Q

How do we treat minimal change disease?

A
  • ) Prenisolone (high relapse rate)

- ) Cyclophosphamide for frequent relapses

247
Q

What is the commonest GN seen on renal biopsy?

A

Focal segmental glomerulosclerosis, FSGS

248
Q

Give 3 secondary causes of FSGS

A
  • ) HIV
  • ) Heroin
  • ) Lithium
  • ) Lymphoma
  • ) Any cause of decreased kidney mass/nephrons
  • ) Kidney scarring
249
Q

Which nephrotic GN doesn’t lead to renal failure?

A

Minimal change disease

250
Q

How do we diagnose FSGS?

A

Glomeruli have scarring of certain segments (focal sclerosis)

251
Q

How do we treat FSGS? (3)

A
  • ) ACEI/ARB and BP control
  • ) Corticosteroids only in idiopathic disease
  • ) Plasma exchange and rituximab for recurrence in transplants
252
Q

What is the equation for STI/HIV transmission?

A 
R=BCD
R - reproductive rate
B - infectivity rate
C - partners over time
D - duration of infection
253
Q

What does chlamydia affect in neonates?

A

Conjunctiva

254
Q

What is the infecting organism in chlamydia?

A

Chlamydia trachomatis

255
Q

What are the symptoms in males with chlamydia? (2)

A
  • ) Dysuria

- ) Urethral discharge

256
Q

What is the % transmission of male to female and female to male in chlamydia?

A

70%

257
Q

Give 2 complications of males with chlamydia

A
  • ) Epididymo-orchititis

- ) Reactive arthritis

258
Q

Give 2 symptoms in females with chlamydia

A
  • ) Discharge
  • ) Menstrual irregularity
  • ) Dysuria
259
Q

In whom is chlamydia more asymptomatic?

A

Females

260
Q

Give 2 complications of females with chlamydia

A
  • ) Pelvic inflammatory disease
  • ) Neonatal transmission
  • ) Fitz Hugh Curtis syndrome
261
Q

How do we diagnose chlamydia?

A
  • ) Nucleic acid amplification tests
  • ) Vaginal and endocervical swab - women
  • ) First void urine - men
262
Q

How do we treat chlamydia? (2)

A
  • ) Azithromycin or doxycycline

- ) Eryhtomycin or azithromycin in pregnancy

263
Q

Which is the most common STI?

A

Chlamydia

264
Q

How does gonorrhoea present in males? (2)

A
  • ) Dysuria

- ) Urethral discharge

265
Q

How does gonorrhoea present in females? (3)

A
  • ) Discharge
  • ) Menstrual irregularity
  • ) Dysuria
266
Q

Give 2 complications of gonorrhoea in females

A
  • ) Pelvic inflammatory disease
  • ) Neonatal transmission
  • ) Fitz Hugh Curtis syndrome
267
Q

What does pelvic inflammatory disease include? (3)

A
  • ) Tubal factor infertility
  • ) Ectopic pregnancy
  • ) Chronic pelvic pain
268
Q

Give a neonatal transmission (STIs)

A
  • ) Ophthalmia neonatorum

- ) Atypical pneumonia

269
Q

How do we diagnose gonorrhoea?

A

Same as for chlamydia

270
Q

What is the causative organism in gonorrhoea?

A

Neisseria gonorrhoeae

271
Q

What STI often occurs in a relationship, and which is associated with recent partner change?

A

Relationship - chlamydia

Change - gonorrhoea

272
Q

What can gonorrhoea cause in babies?

A

Blindness

273
Q

What is the causative organism in syphilis?

A

Treponema pallidum

274
Q

What are the 3 presentations of syphilis?

A
  • ) Primary (<90d after inoculation)
  • ) Secondary (4-10 weeks)
  • ) Tertiary (20-40y)
275
Q

What is the presentation of primary syphilis?

A

-) Macule > papuule > typically painless ulcer (chancre)

276
Q

What is the presentation of secondary syphilis? (4)

A
  • ) Rash
  • ) Mucous patches
  • ) Condyloma late (raised pale plaques)
  • ) Systemic - fever, headache, myalgia, lymphadenopathy, hepatitis
277
Q

What is the presentation of tertiary syphilis? (3)

A
  • ) 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
Q

What is the biggest risk group for syphilis?

A

Men having sex with men

279
Q

How do we diagnose syphilis?

A
  • ) PCR, serology

- ) T. palladim as antigen

280
Q

How do we treat syphilis?

A

IM benzylpenicillin

281
Q

What is primary prevention?

A

Prevent onset of disease

282
Q

What is secondary prevention?

A

Detect and treat disease early

283
Q

What is tertiary prevention?

A

Reduce long term effects of disease

284
Q

What is pre-exposure prophylaxis of HIV?

A

PrEP

285
Q

Give 4 LUTS

A

Storage symptoms:
-) Frequency, nocturne, urgency, urgency incontinenece
Voiding symptoms:
-) Hesitancy, straining, poor/intermittent stream, incomplete emptying
Other:
-) Post micturition dribbling, haematuria, dysuria

286
Q

How do we treat an acute retention of urine?

A

Catheterisation

287
Q

Where do the kidneys lie?

A

Retroperitoneal, T11-L3

288
Q

Where do the ureters run?

A

Over the poses muscle, cross the iliac vessels at the pelvic brim and insert into the trigone of the bladder

289
Q

What type of control does the pelvic nerve have (P/S) of the bladder and sphincter, and what are its roots?

A
  • ) Parasympathetic

- ) S2-4

290
Q

What type of control does the hypogastric plexus have (P/S) of the bladder and sphincter, and what are its roots?

A
  • ) Sympathetic

- ) T11-L2

291
Q

What type of control does the pudendal nerve have (P/S) of the bladder and sphincter, and what are its roots?

A
  • ) Somatic

- ) S2-4

292
Q

What type of nerve is the afferent pelvic nerve, and where is it from?

A
  • ) Sensory nerve

- ) From detrusor muscle

293
Q

What are the 4 main nerves involved in the control of the bladder and sphincter?

A
  • ) Pelvic/parasympathetic nerve
  • ) Hypogastric plexus/sympathetic nerve
  • ) Pudendal/somatic nerve
  • ) Afferent pelvic nerve
294
Q

What are the 4 main control centres involved in the control of the bladder and sphincter?

A
  • ) Cortex
  • ) Pontine micturition centre/periaqueductal grey
  • ) Sacral micturition centre
  • ) Onuf’s nucleus
295
Q

What role does the cortex have in the control of the bladder and sphincter?

A

Voluntary control

296
Q

What role does the pontine micturition centre/PAG have in the control of the bladder and sphincter?

A

Coordination of voiding

297
Q

What role does the sacral micturition centre have in the control of the bladder and sphincter?

A

Micturition reflex

298
Q

What role does Onuf’s nucleus have in the control of the bladder and sphincter?

A

Guarding reflex

299
Q

Why does the pressure in the bladder remain low as the volume increases?

A

Receptive relaxation and detrusor muscle compliance

300
Q

What are the steps of the filling phase? (4)

A

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
Q

What are the steps of the voiding phase? (5)

A

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
Q

What is the guarding reflex?

A

Voluntary control of micturition in anatomically an functionally normal adults when it is inappropriate to void

303
Q

Give the 3 determinants of fluid movement

A
  • ) Hydrostatic pressure
  • ) Osmotic presure
  • ) Oncotic pressure
304
Q

What is hypo/hypervolaemia?

A

Too little/too much fluid

305
Q

What is the pulse like in hypovolaemia?

A

Tachycardic

306
Q

What occurs to creatinine and haemoglobin in hypo/hypervolaemia?

A

Hypo - increased

Hyper - decreased

307
Q

Give 3 sites of fluid accumulation

A
  • ) Pulmonary oedema
  • ) Pleural effusion
  • ) Ascites
  • ) Intraabdominal collection/bleeds
308
Q

Give 2 risk factors for hypovolaemia

A
  • ) Elderly
  • ) Ileostomy/colostomy
  • ) Short bowel syndrome
  • ) Bowel obstruction
  • ) Diuretics
309
Q

Give 2 risk factors for hypervolaemia

A
  • ) AKI
  • ) CKD
  • ) HF
  • ) Liver failure
310
Q

How do we treat hypovolaemia? (3)

A
  • ) Fluid
  • ) Treat cause
  • ) Crystalloid or colloid fluid
311
Q

How do we treat hypervolaemia? (3)

A
  • ) Fluid restriction
  • ) Treat cause
  • ) Diuretics
312
Q

What should not be prescribed in kidney failure patients, and why?

A

Hartmann’s solution, contains potassium

313
Q

Where do loop diuretics work?

A

Loop of Henle

314
Q

Where do thiazide diuretics work?

A

Distal tubule

315
Q

Where do aldosterone antagonists work?

A

Collecting duct

316
Q

Give an example of an aldosterone antagonist

A
  • ) Spironolactone

- ) Potassium sparing diuretic

317
Q

What drugs block aquaporins?

A

Vasopressin antagonists

318
Q

What can renal artery stenosis lead to?

A

Severe hypertension (kidney thinks BP is too low)

319
Q

What do NSAIDs reduce the amount of?

A

Prostaglandin

320
Q

What does prostaglandin do to the glomerulus?

A

Preferentially dilates the afferent arteriole

321
Q

What does angiotensin II do to the glomerulus?

A

Preferentially constricts the efferent arteriole

322
Q

Why should we not prescribe NSAIDs with angiotensin II inhibitors?

A

Drops pressure in glomerulus by
-) Less blood in - NSAIDs
-) More blood out - angiotensin II inhibitors
GFR dramatic decrease, kidney failure

323
Q

You got this?

A

Ofc

324
Q

What protein is found on a dipstick in CKD?

A

Bence Jones

325
Q

What is the mutation in ARPKD?

A

PKHD1

Medicine Year 2 5 (17 decks)

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