Urology Flashcards
Define Acute Kidney Injury
an acute decline in kidney function, leading to a rise in serum creatinine and/or a fall in urine output
results in retention of urea and other nitrogenous waste and the dysregulation of extracellular volume and electrolytes
What are the possible causes of Acute Kidney Injury?
Common causes: ischaemia, sepsis, nephrotoxins
Pre-Kidney (40-70%): anything that causes renal hypoperfusion including hypotension (sepsis, shock, anaphylaxis), hypovolaemia (haemorrhage, severe vomiting), renal artery stenosis (ACEi, NSAIDs), heart failure, cirrhosis
Kidney (10-25%): cellular damage, glomerular (glomerulonephritis, autoimmune e.g. SLE), interstitial nephritis (acute interstitial nephritis), tubular (acute tubular necrosis), vascular (haemolytic uraemic syndrome, large vessel occlusion), eclampsia
Post-Kidney: urinary tract obstructions, retroperitoneal fibrosis, lymphoma, tumour, prostate hyperplasia, strictures, renal calculi, ascending urinary infection (including pyelonephritis), and urinary retention
Risk Factors of Acute Kidney Injury
Over 75 Chronic Kidney Disease Comorbidities Sepsis Hypovolaemia Use of nephrotoxic medications Poor fluid intake / increases losses Emergency surgery History of urinary symptoms
Epidemiology of Acute Kidney Injury
18% of adults admitted to hospital will develop an AKI
Most common in elderly
Presenting Symptoms of Acute Kidney Injury
Really depends on the underlying cause
Oliguria / anuria (abrupt anuria suggests post-renal obstruction)
Nausea / vomiting
Dehydration
Confusion
Signs of Acute Kidney Injury on examination
Prioritise sepsis screen and volume status
- Hypotension (common cause of reduced perfusion, due to acute illness e.g. sepsis, haemorrhage or poor fluid balance)
- Hypovolaemia (JVP, BP, capillary refill)
- Distended Bladder (suggests obstruction)
- Renal Bruit (renovascular disease)
- Dehydration (postural hypotension)
- Fluid overload (in heart failure, cirrhosis, nephrotic syndrome), raised JVP, pulmonary and peripheral oedema
- Pallor, rash, bruising (vascular disease)
KDIGO Classification of Acute Kidney Injury
A rise in serum creatinine of ≥26 micromol/L (≥0.3 mg/dL) within 48 hours
A rise in serum creatinine to ≥1.5 times baseline, which is known or presumed to have occurred within the past 7 days
Urine volume <0.5 ml/kg/hour for at least 6 hours.
What investigations would you order for suspected Acute Kidney Injury?
Always start with ABCDE approach and check for urgent K+ on venous blood specimen and ECG to check for life-threatening hyperkalaemia
- Bloods
Urea and electrolytes (including creatinine and bicarbonate) are the key investigations.
Also request liver function tests, C-reactive protein, full blood count, and blood cultures if infection suspected.
- Urinalysis
If positive for both protein and blood (in the absence of a urinary tract infection or catheterisation), consider the possibility of an intrinsic cause
Nitrites and leukocytes may indicate infection - send urine culture.
- Routine renal tract ultrasound is not needed if a clear cause has been identified. Only request it if:
There is no clear cause of AKI
Pyelonephritis or pyonephrosis is suspected (if pyonephrosis is suspected, ensure the patient has an ultrasound within 6 hours because of the risk of septic shock)
Urinary tract obstruction is suspected (the ultrasound should be performed within 24 hours at the latest).
Management plan for a patient with suspected Acute Kidney Injury
- Start with ABCDE approach
- Check for hyperkalaemia
- Assess volume status
- Aim for euvolaemia
- Stop nephrotoxic drugs (ACEi, NSAIDs)
- Monitor fluid status, U&Es
- Treat the underlying cause:
1. Pre-renal = correct volume depletion with fluids, sepsis with antibiotics
2. Post-renal = catheterise and consider CT of renal tract and urology referral if obstruction likely cause
3. Intrinsic = refer to nephrology - Renal replacement therapy = dialysis
Prognosis for patients with Acute Kidney Injury
· Inpatient mortality varies depending on cause and comorbidities, and early recognition
· Indicators of poor prognosis:
o Age
o Multiple organ failure
o Oliguria
o Hypotension
o CKD
· Patients who develop AKI are at increased risk of developing CKD
Define Urinary Tract Calculi
Crystal deposition within the urinary tract, aka nephrolithiasis
Can deposit in kidneys, ureters, bladder or urethra
What types of stone can form in Urinary Tract Calculi
calcium oxalate struvite uric acid calcium phosphate cysteine
Risk factors and aetiology of developing Urinary Tract Calculi
- Metabolic - hypercalciuria, hyperuricaemia, hypercystinuria, hyperoxaluria, hyperparathyroidism, renal tubular acidosis
- Infection - hyperuricaemia, recurrent UTIs
- Drugs - indinavir, diuretics, antacids, corticosteroids
- Abnormalities - pelviureteric junction obstruction, hydronephrosis, ureteral stricture
- Foreign bodies - catheters
Risk Factors: low fluid intake, males, 20-50 yrs, chocolate, tea, rhubarb, strawberries, nuts, spinach - increase oxalate, structural abnormalities, obese, white
Presenting Symptoms of Urinary Tract Calculi
- renal colic
- flank pain if pelvis or proximal ureter
- loin to groin if lower in ureter
- sometimes asymptomatic
- nausea and vomiting
- haematuria
- distal ureter stone would cause dysuria and urgency
Signs of Urinary Tract Calculi on examination
- loin to lower abdomen tenderness
- no peritonism
- AAA is main differential in older men
- signs of sepsis if obstruction and infection above the stone
Investigations for Urinary Tract Calculi
- Urine dipstick for microscopic haematuria
- CT-KUB
- USS (if pregnant do this instead of CT)
- U&Es
- Pregnancy Test
Treatment of Urinary Tract Calculi
(a) ACUTE - hydration and analgesia with bed rest
- urine collection to retrieve stone that passes (if less than 5mm)
- obstructed, infected kidney should be removed and give Abx
(b) CONTROLLED - Medical expulsive therapy
- give fluids and alpha blocker or calcium channel blocker to promote expulsion
(c) REMOVAL
- Urethroscopy: scope passed into bladder and ureter to remove/break stone
- Stent to expand ureter to allow urine to flow
- Extracorporeal shock wave lithotripsy: uses electromagnetic waves to break stone
- Percutaneous nephrolithotomy: goes straight into kidney via back, for large, complex stones
Prognosis for Urinary Tract Calculi
- good
- infection may lead to irreversible renal scarring
- recurrence of about 50% over 5 years
What are Urinary Tract Infections?
- infection of kidneys, bladder or urethra
- Lower UTI = urethritis, cystitis or prostatitis
- Upper UTI = pyelonephritis
- Uncomplicated = normal tract and function, unobstructed
- Complicated = abnormal tract, voiding issues, reduced renal function, impaired host defences, virulent organism e.g. S.aureus
What are the causes of Urinary Tract Infections?
Usually Escherichia coli (about 80% of all uncomplicated cases)
Can also be Staphylococcus saprophyticus
Enterobacteriaceae (proteus mirabilis, klebsiella)
Enterococci
Pseudomonas aeruginosa
Risk factors of Urinary Tract Infections?
- females
- sex
- spermicide exposure
- pregnancy
- post-meonpause
- immunosuppression
- catheterisation
- urinary obstruction
- urinary tract malformation
Epidemiology of Urinary Tract Infections
- females
- very common
- 1-3% of all GP consultations
Presenting Symptoms of Urinary Tract Infection
- Cystitis = frequency, urgency, dysuria, haematuria, suprapubic pain, cloudy-looking urine, nocturia
- Prostatitis = flu-like, low backache, few urinary symptoms, swollen or tender prostate
- Pyelonephritis = high fever, rigors, vomiting, loin pain and tenderness, oliguria (if AKI)
Signs of Urinary Tract Infection on examination
- fever
- abdominal or loin tenderness
- foul-smelling urine
- distended bladder (sometimes)
- enlarged prostate (prostatitis)
Investigations for Urinary Tract Infection
- Urine dipstick looks for nitrites and leukocytes
- Urine Microscopy to look for leukocytes
- Urine culture to exclude diagnosis or to see if patient has failed to respond to empirical antibiotics
- US to rule out obstruction
- Bloods (FBC, U&Es, CRP, Blood cultures)
Treatment of Urinary Tract Infections
- Empirical antibiotics: TRIMETHORPIN or NITROFURANTOIN
- 3-6 days, men may need longer
- Alternative = co-amoxiclav or cefalexin
What is multiple myeloma?
haematological malignancy of plasma cells resulting in a large number of a specific antibody being produced
results in bone lesions and production of lots of a monoclonal immunoglobulin (usually IgG or IgA)
Presenting symptoms of multiple myeloma
CRAB
- High calcium due to plasma cells causing increased osteoclast activity and suppressed osteoblast activity - fractures or pain in spine, long bones, ribs
- Renal failure due to immunoglobulins blocking the tubules resulting in dehydration, polyuria
- Anaemia, neutropenia and thrombocytopenia due to suppression of development of other blood cell lines
- Bone lesions and pain
- Raised plasma viscosity will cause easy bruising, easy bleeding, reduced or loss of sight, heart failure, purple palmar erythema
Signs of multiple myeloma on examination
- pallor
- tachycardia
- flow murmur
- heart failure
- dehydration
- purpura
- macroglossia
- peripheral neuropathies
- low WBC in FBC
- raised calcium
- ESR raised
- increased plasma viscosity
- back pain or unexplained fractures
- punched out lesions
- lytic lesions
- raindrop skull
Investigations for multiple myeloma
- Bloods
- Serum protein electrophoresis
BLIP
- Bence-Jones protein urine test
- Serum free light chain assay
- serum immunoglobulins
- serum protein electrophoresis
- bone marrow biopsy to confirm
- imaging for bone lesions
- MRI then CT then skeletal survey (x-ray)
How would you manage multiple myeloma?
- aim is to control disease
- Chemo + bortezomib, thalidomide and dexamethasone
- bisphosphonates to suppress osteoclast activity
What is benign prostatic hyperplasia?
- very common condition affecting older men where there is hyperplasia of the stromal and epithelial cells of the prostate causing LUTS
Symptoms of BPH
- hesitancy
- weak flow
- urgency
- frequency
- intermittent stream
- straining
- terminal dribbling
- incomplete emptying
- nocturia
Signs of BPH on examination
- DRE will be smoothly enlarged with a palpable midline groove
- suprapubic pain and distended palpable bladder indicates acute retention
- large distended painless bladder suggests chronic retention
Investigations for BPH
Urinalysis to check to UTIs and blood
Bloods - U&Es to check renal function and also PSA
Midstream urine
US KUB
Management for BPH
- Conservative: watchful waiting if mild BPH
- Medical: selective alpha blockers to relax muscles, 5 alpha reductase inhibitors to inhibit testosterone to dihydrotestosterone, to reduce prostate size by around 20%
- Surgery: TURP, TUIP, open prostatectomy
What is bladder cancer?
- malignancy of bladder cells
- most are transitional cell carcinoma
- rarely they may be squamous cell carcinoma
What are the risk factors for developing bladder cancer?
- smoking
- increased age
- aromatic amines (rubber, dye industry)
- schistosomiasis
How does bladder cancer present?
- over 45 with painless haematuria without UTI or persisting after treatment for UTI
- over 60 with microscopic haematuria plus dysuria or raised WBC
- frequency, urgency, nocturia, voiding irritability
Investigations for bladder cancer
- cystoscopy
- urine microscopy
- ultrasound
- CT/MRI for staging
Treatment of bladder cancer
- TURBT for non-muscle invasive bladder cancer
- Intravesical chemo to reduce recurrence risk
- Cystectomy
What are epididymitis and orchitis?
- inflammation of the epididymis or testes
- usually associated with each other
What are the causes of epididymitis and orchitis?
- usually infection
1. Bacterial = chalmydia and gonococcus if <35 and mainly coliforms if >35
2. Viral = mumps
3. Fungal = candida if immunocompromised
1/3 are idiopathic
Symptoms of epididymitis and orchitis
- painful, swollen and tender testis or epididymis
- sudden onset but less acute onset than testicular torsion
- penile discharge
- dysuria
- sweats/fever
Signs of epididymitis and orchitis
- swollen and tender epididymis or testis
- scrotum may be erythematous and oedematous
- pyrexia
- walking will be painful
- cremasteric reflex will be painful
Investigations for epididymitis and orchitis
- distinguish if sexually transmitted organism or an enteric organism
- more likely sexual if under 35, increased partners or discharge from urethra
- urine microscopy, culture and sensitivity
- chlamydia and gonorrhoea
- saliva swab (mumps)
- US for torsion or tumour
Managing epididymitis and orchitis
- Medical: doxycylcine if under 35, add ceftriaxone if suspected gonorrhoea
If over 35 then UTI suspected, try ciprofoxaicin or ofloxacin
- Surgical: exploration if can’t rule out testicular torsion or to drain any abscess
Complications of epididymitis and orchitis
chronic pain, chronic epididymitis, testicular atrophy, sub-fertility, scrotal abscess
What is chronic kidney disease?
Progressive kidney damage or eGFR of <60 ml/min/1.73m^2 for 3 months
What are the risk factors and causes of chronic kidney disease?
Diabetes, hypertension, old age, glomerulonephritis, polycystic kidney disease, NSAIDs, PPIs, lithium
Signs and symptoms of chronic kidney disease
Usually asymptomatic
Pruritis, loss of appetite, nausea, oedema, muscle cramps, peripheral neuropathy, pallor, hypertension
Kussmaul’s breathing, anaemia, oedema, leuconychia, arteriovenous fistula.
Investigations for chronic kidneys disease
Bloods: reduced Hb, normocytic U&E: increased urea and creatinine eGFR Reduced calcium Increased phosphate
Urine collection 24 hr: protein
Imaging: osteomalacia and hyperparathyroidism
Management of chronic kidney disease
- control diabetes
- exercise
- stop smoking
- atorvaststin for primary prevention of cardiovascular disease
- iron for anaemia, erythropoietin after iron
- ACE inhibitors and angiotensin II antagonists for BP (watch out for hyperkalaemia)
- low phosphate diet
- vitamin D for renal bone disease
- dialysis or transplant at end stage
- sodium bicarbonate for metabolic acidosis
- avoid nephrotoxic drugs
In dialysis, bicarbonate is at a higher concentration in the blood or diasylate fluid? And why?
Higher in dialsylate so it can diffuse into blood
In CKD you can’t retain enough bicarbonate so you’re at greater risk of acidosis
In dialysis, potassium is at a higher concentration in blood or diasylate?
Blood because it needs to diffuse out
In CKD, less potassium is excreted so at greater risk of hyperkalaemia
A 70-year-old man has presented to the pre-dialysis clinic for review. He has been feeling increasingly lethargic over the last 6 months. His blood tests reveal a stable serum creatinine concentration, however, the patient is anaemic with a haemoglobin of 86 g/L. Which of the following treatments is most appropriate for this patient?
Erythropoietin alpha
What is diabetic nephropathy?
Damage to the kidneys as a result of diabetes
Symptoms of diabetic nephropathy
Peipeheral oedema, increased frequency, confusion, SOB, loss of appetite, nausea and vomiting, pruritis, fatigue
Diagnosing diabetic nephropathy
Proteinuria
Diabetic require regular albumin:creatinine ratio checks and U&Es
How is diabetic nephropathy managed?
Optimise blood sugar levels and blood pressure
Stop smoking
Exercise
ACE inhibitor
What is testicular cancer?
- malignant tumour of the testes, arises from the germ cells
- can be seminomas or non-seminomas
Where does prostate cancer commonly spread to?
- lymph nodes and bones
Prostate cancer is _____ dependent
androgen
The majority of prostate cancers are _____
adenocarcinomas
Risk factors for developing prostate cancer
- increasing age
- family history
- obesity
- black African or Caribbean
How does prostate cancer present?
- often asymptomatic
- eventually will cause LUTS
- haematuria, haematospermia
- pain in back or pelvis if metastasised
What can cause a raised PSA?
- BPH
- prostatitis
- prostate cancer
- ejaculation
- urinary retention
- vigorous exercise
How should suspected prostate cancer be investigated?
- DRE, hard nodular prostate, loss of midline sulcus
- Bloods
- MRI is first-line
- PSA
- trans rectal biopsy after MRI
What scale is used to grade prostate cancer?
Gleason scale
- based on histology from biopsy
- two numbers from (1-5) added together
How is prostate cancer managed?
- surveillance and watchful waiting if localised to prostate and early, or if old
- radiotherapy
- surgery if still young and localised to prostate
- hormone therapy to reduce androgens (androgen-receptor blockers, GnRH agonists, bilateral orchidectomy)
What is nephrotic syndrome?
- basement membrane becomes highly permeable to protein, allowing proteins to leak from the blood into the urine
- most common between 2 and 5
- forthy urine, generaised oedema and pallor
Nephrotic syndrome is a classic triad of:
- low serum albumin
- high urine protein
- oedema
Features of nephrotic syndrome
- low serum albumin
- high urine protein
- oedema
- deranged lipid profile
- high BP
- hyper-coagulability
Causes of nephrotic syndrome
- minimal change disease (in children with no clear cause)
- secondary to intrinsic kidney disease (glomerulonephritis)
- secondary to underlying systemic illness (henoch schonlein purpura, diabetes, infection)
What is minimal change disease and how is it managed?
- most common cause of nephrotic syndrome in children
- no clear risk factors or reason for developing the condition
- renal biopsy and standard microscopy won’t detect anything
- urinalysis will show small molecular weight proteins and hyaline casts
- treated with corticosteroids
How is nephrotic syndrome managed?
- high dose steroids
- low salt diet
- diuretics for oedema
- ## albumin infusion if severe hypalbuminaemia
Complications of nephrotic syndrome
- hypovolaemia due to loss of fluid into intravascular space
- thrombosis due to loss of clotting factors (proteins)
- infection due to leakage of immunoglobulins
- acute or chronic renal failure
What are the risk factors for testicular cancer?
- undescended testes
- male infertility
- family history
- increased height
How does testicular cancer present?
- painless lump on testicle
- sometimes a bit of pain
- non-tender
- arising from testicle
- hard
- irregular
- not fluctuant
- no transillumination
- leydig cell tumour may also present with gynaecomastia
Investigations for testicular cancer?
- scrotal US to confirm diagnosis
- tumour markers:
- alpha-fetoprotein = teratomas
- beta hCG = raised in both
- lactate dehydrogenase is non-specific
- staging CT to check spread
What is the Royal Marsden staging system?
for testicular cancer
- Stage 1: isolated to testicle
- Stage 2: spread to retroperitoneal lymph nodes
- Stage 3: spread to lymph nodes above the diaphragm
- Stage 4: metastasised to other organs
Common areas for testicular cancer to spread to?
- lymphatics
- lungs
- liver
- brain
How is testicular cancer managed? Side effects
- surgery
- chemo
- radio
- sperm banking
- infertility
- hypogonadism
- peripheral neuropathy
- hearing loss
- lasting kidney, liver or heart failure
What is testicular torsion?
- twisting of the spermatic cord with rotation of the testicle
delay in treatment will cause ischaemia and necrosis, leading to sub-fertility or infertility
Presentation and signs of testicular torsion
- often triggered by activity
- presents with acute rapid onset of unilateral testicular pain and may be associated with abdominal pain and vomiting
- can sometimes just be abdominal pain
- firm swollen testicle
- elevated testicle
- absent cremasteric reflex
- abnormal testicular lie
- rotation, so that epididymis is not in normal posterior position
What is the bell-clapper deformity?
- one of the causes of testicular torsion
- fixation between testicle and tunica vaginalis is absent
- testicle hangs in a horizontal position
How is testicular torsion treated?
urological emergency
- NBM
- analgesia
- urgent senior urology assessment
- surgical exploration of the scrotum
- orchiopexy
- orchidectomy if surgery is delayed or if there is necrosis
- scrotal US can confirm diagnosis but any investigation will delay the patient going to theatre is not recommended
- US will show whirlpool sign
