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3rd Year Conditions > Urology > Flashcards

Urology Flashcards

1
Q

Define Acute Kidney Injury

A

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

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2
Q

What are the possible causes of Acute Kidney Injury?

A

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

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3
Q

Risk Factors of Acute Kidney Injury

A 
Over 75
Chronic Kidney Disease
Comorbidities
Sepsis
Hypovolaemia
Use of nephrotoxic medications
Poor fluid intake / increases losses
Emergency surgery
History of urinary symptoms
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4
Q

Epidemiology of Acute Kidney Injury

A

18% of adults admitted to hospital will develop an AKI

Most common in elderly

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5
Q

Presenting Symptoms of Acute Kidney Injury

A

Really depends on the underlying cause

Oliguria / anuria (abrupt anuria suggests post-renal obstruction)

Nausea / vomiting

Dehydration

Confusion

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6
Q

Signs of Acute Kidney Injury on examination

A

Prioritise sepsis screen and volume status

  1. Hypotension (common cause of reduced perfusion, due to acute illness e.g. sepsis, haemorrhage or poor fluid balance)
  2. Hypovolaemia (JVP, BP, capillary refill)
  3. Distended Bladder (suggests obstruction)
  4. Renal Bruit (renovascular disease)
  5. Dehydration (postural hypotension)
  6. Fluid overload (in heart failure, cirrhosis, nephrotic syndrome), raised JVP, pulmonary and peripheral oedema
  7. Pallor, rash, bruising (vascular disease)
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7
Q

KDIGO Classification of Acute Kidney Injury

A

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.

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8
Q

What investigations would you order for suspected Acute Kidney Injury?

A

Always start with ABCDE approach and check for urgent K+ on venous blood specimen and ECG to check for life-threatening hyperkalaemia

  1. 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.

  1. 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.

  1. 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).

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9
Q

Management plan for a patient with suspected Acute Kidney Injury

A
  • 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
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10
Q

Prognosis for patients with Acute Kidney Injury

A

· 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

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11
Q

Define Urinary Tract Calculi

A

Crystal deposition within the urinary tract, aka nephrolithiasis

Can deposit in kidneys, ureters, bladder or urethra

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12
Q

What types of stone can form in Urinary Tract Calculi

A 
calcium oxalate
struvite
uric acid
calcium phosphate
cysteine
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13
Q

Risk factors and aetiology of developing Urinary Tract Calculi

A
  1. Metabolic - hypercalciuria, hyperuricaemia, hypercystinuria, hyperoxaluria, hyperparathyroidism, renal tubular acidosis
  2. Infection - hyperuricaemia, recurrent UTIs
  3. Drugs - indinavir, diuretics, antacids, corticosteroids
  4. Abnormalities - pelviureteric junction obstruction, hydronephrosis, ureteral stricture
  5. Foreign bodies - catheters

Risk Factors: low fluid intake, males, 20-50 yrs, chocolate, tea, rhubarb, strawberries, nuts, spinach - increase oxalate, structural abnormalities, obese, white

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14
Q

Presenting Symptoms of Urinary Tract Calculi

A
  • 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
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15
Q

Signs of Urinary Tract Calculi on examination

A
  • loin to lower abdomen tenderness
  • no peritonism
  • AAA is main differential in older men
  • signs of sepsis if obstruction and infection above the stone
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16
Q

Investigations for Urinary Tract Calculi

A
  1. Urine dipstick for microscopic haematuria
  2. CT-KUB
  3. USS (if pregnant do this instead of CT)
  4. U&Es
  5. Pregnancy Test
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17
Q

Treatment of Urinary Tract Calculi

A

(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

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18
Q

Prognosis for Urinary Tract Calculi

A
  • good
  • infection may lead to irreversible renal scarring
  • recurrence of about 50% over 5 years
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19
Q

What are Urinary Tract Infections?

A
  • 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
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20
Q

What are the causes of Urinary Tract Infections?

A

Usually Escherichia coli (about 80% of all uncomplicated cases)

Can also be Staphylococcus saprophyticus

Enterobacteriaceae (proteus mirabilis, klebsiella)

Enterococci

Pseudomonas aeruginosa

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21
Q

Risk factors of Urinary Tract Infections?

A
  • females
  • sex
  • spermicide exposure
  • pregnancy
  • post-meonpause
  • immunosuppression
  • catheterisation
  • urinary obstruction
  • urinary tract malformation
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22
Q

Epidemiology of Urinary Tract Infections

A
  • females
  • very common
  • 1-3% of all GP consultations
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23
Q

Presenting Symptoms of Urinary Tract Infection

A
  1. Cystitis = frequency, urgency, dysuria, haematuria, suprapubic pain, cloudy-looking urine, nocturia
  2. Prostatitis = flu-like, low backache, few urinary symptoms, swollen or tender prostate
  3. Pyelonephritis = high fever, rigors, vomiting, loin pain and tenderness, oliguria (if AKI)
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24
Q

Signs of Urinary Tract Infection on examination

A
  • fever
  • abdominal or loin tenderness
  • foul-smelling urine
  • distended bladder (sometimes)
  • enlarged prostate (prostatitis)
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25
Q

Investigations for Urinary Tract Infection

A
  1. Urine dipstick looks for nitrites and leukocytes
  2. Urine Microscopy to look for leukocytes
  3. Urine culture to exclude diagnosis or to see if patient has failed to respond to empirical antibiotics
  4. US to rule out obstruction
  5. Bloods (FBC, U&Es, CRP, Blood cultures)
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26
Q

Treatment of Urinary Tract Infections

A
  1. Empirical antibiotics: TRIMETHORPIN or NITROFURANTOIN
  2. 3-6 days, men may need longer
  3. Alternative = co-amoxiclav or cefalexin
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27
Q

What is multiple myeloma?

A

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)

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28
Q

Presenting symptoms of multiple myeloma

A

CRAB

  1. High calcium due to plasma cells causing increased osteoclast activity and suppressed osteoblast activity - fractures or pain in spine, long bones, ribs
  2. Renal failure due to immunoglobulins blocking the tubules resulting in dehydration, polyuria
  3. Anaemia, neutropenia and thrombocytopenia due to suppression of development of other blood cell lines
  4. Bone lesions and pain
  5. Raised plasma viscosity will cause easy bruising, easy bleeding, reduced or loss of sight, heart failure, purple palmar erythema
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29
Q

Signs of multiple myeloma on examination

A
  • 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
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30
Q

Investigations for multiple myeloma

A
  1. Bloods
  2. 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)
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31
Q

How would you manage multiple myeloma?

A
  • aim is to control disease
  • Chemo + bortezomib, thalidomide and dexamethasone
  • bisphosphonates to suppress osteoclast activity
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32
Q

What is benign prostatic hyperplasia?

A
  • very common condition affecting older men where there is hyperplasia of the stromal and epithelial cells of the prostate causing LUTS
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33
Q

Symptoms of BPH

A
  • hesitancy
  • weak flow
  • urgency
  • frequency
  • intermittent stream
  • straining
  • terminal dribbling
  • incomplete emptying
  • nocturia
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34
Q

Signs of BPH on examination

A
  • 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
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35
Q

Investigations for BPH

A

Urinalysis to check to UTIs and blood

Bloods - U&Es to check renal function and also PSA

Midstream urine

US KUB

36
Q

Management for BPH

A
  1. Conservative: watchful waiting if mild BPH
  2. Medical: selective alpha blockers to relax muscles, 5 alpha reductase inhibitors to inhibit testosterone to dihydrotestosterone, to reduce prostate size by around 20%
  3. Surgery: TURP, TUIP, open prostatectomy
37
Q

What is bladder cancer?

A
  • malignancy of bladder cells
  • most are transitional cell carcinoma
  • rarely they may be squamous cell carcinoma
38
Q

What are the risk factors for developing bladder cancer?

A
  • smoking
  • increased age
  • aromatic amines (rubber, dye industry)
  • schistosomiasis
39
Q

How does bladder cancer present?

A
  • 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
40
Q

Investigations for bladder cancer

A
  • cystoscopy
  • urine microscopy
  • ultrasound
  • CT/MRI for staging
41
Q

Treatment of bladder cancer

A
  • TURBT for non-muscle invasive bladder cancer
  • Intravesical chemo to reduce recurrence risk
  • Cystectomy
42
Q

What are epididymitis and orchitis?

A
  • inflammation of the epididymis or testes

- usually associated with each other

43
Q

What are the causes of epididymitis and orchitis?

A
  • 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

44
Q

Symptoms of epididymitis and orchitis

A
  • painful, swollen and tender testis or epididymis
  • sudden onset but less acute onset than testicular torsion
  • penile discharge
  • dysuria
  • sweats/fever
45
Q

Signs of epididymitis and orchitis

A
  • swollen and tender epididymis or testis
  • scrotum may be erythematous and oedematous
  • pyrexia
  • walking will be painful
  • cremasteric reflex will be painful
46
Q

Investigations for epididymitis and orchitis

A
  • 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
47
Q

Managing epididymitis and orchitis

A
  1. Medical: doxycylcine if under 35, add ceftriaxone if suspected gonorrhoea

If over 35 then UTI suspected, try ciprofoxaicin or ofloxacin

  1. Surgical: exploration if can’t rule out testicular torsion or to drain any abscess
48
Q

Complications of epididymitis and orchitis

A

chronic pain, chronic epididymitis, testicular atrophy, sub-fertility, scrotal abscess

49
Q

What is chronic kidney disease?

A

Progressive kidney damage or eGFR of <60 ml/min/1.73m^2 for 3 months

50
Q

What are the risk factors and causes of chronic kidney disease?

A

Diabetes, hypertension, old age, glomerulonephritis, polycystic kidney disease, NSAIDs, PPIs, lithium

51
Q

Signs and symptoms of chronic kidney disease

A

Usually asymptomatic

Pruritis, loss of appetite, nausea, oedema, muscle cramps, peripheral neuropathy, pallor, hypertension

Kussmaul’s breathing, anaemia, oedema, leuconychia, arteriovenous fistula.

52
Q

Investigations for chronic kidneys disease

A 
Bloods: reduced Hb, normocytic
U&E: increased urea and creatinine 
eGFR
Reduced calcium
Increased phosphate

Urine collection 24 hr: protein

Imaging: osteomalacia and hyperparathyroidism

53
Q

Management of chronic kidney disease

A
  • 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
54
Q

In dialysis, bicarbonate is at a higher concentration in the blood or diasylate fluid? And why?

A

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

55
Q

In dialysis, potassium is at a higher concentration in blood or diasylate?

A

Blood because it needs to diffuse out

In CKD, less potassium is excreted so at greater risk of hyperkalaemia

56
Q

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?

A

Erythropoietin alpha

57
Q

What is diabetic nephropathy?

A

Damage to the kidneys as a result of diabetes

58
Q

Symptoms of diabetic nephropathy

A

Peipeheral oedema, increased frequency, confusion, SOB, loss of appetite, nausea and vomiting, pruritis, fatigue

59
Q

Diagnosing diabetic nephropathy

A

Proteinuria

Diabetic require regular albumin:creatinine ratio checks and U&Es

60
Q

How is diabetic nephropathy managed?

A

Optimise blood sugar levels and blood pressure

Stop smoking

Exercise

ACE inhibitor

61
Q

What is testicular cancer?

A
  • malignant tumour of the testes, arises from the germ cells
  • can be seminomas or non-seminomas
62
Q

Where does prostate cancer commonly spread to?

A
  • lymph nodes and bones
63
Q

Prostate cancer is _____ dependent

A

androgen

64
Q

The majority of prostate cancers are _____

A

adenocarcinomas

65
Q

Risk factors for developing prostate cancer

A
  • increasing age
  • family history
  • obesity
  • black African or Caribbean
66
Q

How does prostate cancer present?

A
  • often asymptomatic
  • eventually will cause LUTS
  • haematuria, haematospermia
  • pain in back or pelvis if metastasised
67
Q

What can cause a raised PSA?

A
  • BPH
  • prostatitis
  • prostate cancer
  • ejaculation
  • urinary retention
  • vigorous exercise
68
Q

How should suspected prostate cancer be investigated?

A
  • DRE, hard nodular prostate, loss of midline sulcus
  • Bloods
  • MRI is first-line
  • PSA
  • trans rectal biopsy after MRI
69
Q

What scale is used to grade prostate cancer?

A

Gleason scale

  • based on histology from biopsy
  • two numbers from (1-5) added together
70
Q

How is prostate cancer managed?

A
  • 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)
71
Q

What is nephrotic syndrome?

A
  • 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
72
Q

Nephrotic syndrome is a classic triad of:

A
  • low serum albumin
  • high urine protein
  • oedema
73
Q

Features of nephrotic syndrome

A
  • low serum albumin
  • high urine protein
  • oedema
  • deranged lipid profile
  • high BP
  • hyper-coagulability
74
Q

Causes of nephrotic syndrome

A
  • 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)
75
Q

What is minimal change disease and how is it managed?

A
  • 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
76
Q

How is nephrotic syndrome managed?

A
  • high dose steroids
  • low salt diet
  • diuretics for oedema
  • ## albumin infusion if severe hypalbuminaemia
77
Q

Complications of nephrotic syndrome

A
  • 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
78
Q

What are the risk factors for testicular cancer?

A
  • undescended testes
  • male infertility
  • family history
  • increased height
79
Q

How does testicular cancer present?

A
  • 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
80
Q

Investigations for testicular cancer?

A
  • 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
81
Q

What is the Royal Marsden staging system?

A

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
82
Q

Common areas for testicular cancer to spread to?

A
  • lymphatics
  • lungs
  • liver
  • brain
83
Q

How is testicular cancer managed? Side effects

A
  • surgery
  • chemo
  • radio
  • sperm banking
  • infertility
  • hypogonadism
  • peripheral neuropathy
  • hearing loss
  • lasting kidney, liver or heart failure
84
Q

What is testicular torsion?

A
  • twisting of the spermatic cord with rotation of the testicle
    delay in treatment will cause ischaemia and necrosis, leading to sub-fertility or infertility
85
Q

Presentation and signs of testicular torsion

A
  • 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
86
Q

What is the bell-clapper deformity?

A
  • one of the causes of testicular torsion
  • fixation between testicle and tunica vaginalis is absent
  • testicle hangs in a horizontal position
87
Q

How is testicular torsion treated?

A

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

3rd Year Conditions (16 decks)

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