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Phase 2a Medicine > Urology > Flashcards

Urology Flashcards

1
Q

What are the three functions of the urinary tract?

A
  1. To collect urine produced by the kidneys
  2. To store urine collected safely
  3. To expel urine when socially acceptable
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2
Q

Where are the kidneys situated?

A

Retroperitoneal, between T11-L3

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3
Q

Where do the kidneys get their blood supply from?

A

Renal artery, which comes directly from the aorta at L1 level

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4
Q

Where is the prostate gland situated?

A

At the neck of the bladder

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5
Q

What are the four nerves controlling the bladder and sphincter?

A
  1. Pelvic nerve (involuntary)
  2. Hypogastric plexus (involuntary)
  3. Pudendal nerve (voluntary)
  4. Afferent pelvic nerve (sensory)
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6
Q

Which neurotransmitters are used in control of the bladder and sphincter?

A

ACh via the pelvic (parasympathetic) and pudendal (somatic) nerves.
Noradrenaline via the hypogastric plexus (sympathetic).

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7
Q

The afferent pelvic nerve carries sensory signals from which muscle?

A

Detrusor

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8
Q

Which parts of the brain control coordination of voiding?

A

Pontine micturition centre/periaqueductal grey

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9
Q

What controls the micturition reflex?

A

Sacral micturition centre

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10
Q

What controls the guarding reflex?

A

Onuf’s nucleus

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11
Q

What are the three phases of voiding?

A 
Storage phase (98% of the time) 
Guarding reflex (if micturition inappropriate)
Micturition reflex (if micturition appropriate)
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12
Q

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

A

Due to receptive relaxation and detrusor muscle compliance

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13
Q

What do the nerves supplying the urinary tract do during the filling phase?

A
  • Afferent pelvic nerve sends slow firing signals to the pons via the spinal cord
  • Sympathetic stimulation via the hypogastric plexus maintains detrusor muscle relaxation
  • Pudendal nerve stimulation maintains urethral contraction
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14
Q

Describe the micturition reflex

A
  • Higher volumes in the bladder stimulate the afferent pelvic nerve to send fast signals to the sacral micturition centre in the sacral spinal cord
  • The pelvic parasympathetic nerve is stimulated and the detrusor muscle contracts
  • The pudendal nerve is inhibited and the external sphincter relaxes
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15
Q

Describe what happens during bladder emptying

A
  • Coordinated detrusor contraction with external sphincter relaxation expels urine from the bladder
  • A positive feedback loop is generated until all the urine is expelled
  • Once complete, the detrusor relaxes and the external sphincter contracts.
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16
Q

Describe the guarding reflex

A
  • Occurs when voiding is inappropriate, which is determined by afferent signals from the pelvic nerve being received by the PMC and PAG and being transmitted to higher cortical centres
  • Sympathetic (hypogastric) nerve stimulation results in detrusor relaxation
  • Pudendal nerve stimulation results in contraction of the external urethral sphincter
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17
Q

What are the lower urinary tract symptoms related to storage?

A

Frequency
Urgency
Nocturia

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18
Q

What are the lower urinary tract symptoms related to voiding?

A 
Weak/intermittent stream
Incomplete emptying
Straining
Hesitancy
Terminal dribbling
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19
Q

What is benign prostatic hyperplasia?

A

Increased number of cells in the prostate, caused by epithelial and stroma proliferation or decreased apoptosis

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20
Q

What is benign prostatic enlargement?

A

Enlarged prostate found during physical examination/urological investigation

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21
Q

What can contribute to BPH?

A

Androgens, oestrogen, stromal epithelial interactions, growth factors and neurotransmitters

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22
Q

What is the role of androgens in BPH?

A
  • Do not actually cause it, but required for BPH to occur.
  • Androgen withdrawal can involute established BPH
  • If androgen action/production is completely inhibited, BPH does not occur.
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23
Q

What is active benign prostatic obstruction?

A

Obstruction caused by contraction of the alpha-1 adrenoreceptor mediated smooth muscle

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24
Q

What is passive benign prostatic obstruction?

A

Obstruction caused by the volume effect of BPE

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25
Q

What scoring system can be used to assess patients with prostate-related symptoms?

A

IPSS - International Prostate Symptom Score, consists of 7 questions, graded 0-5

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26
Q

What are the first line investigations for a male patient with lower urinary tract symptoms?

A
  • General examination
  • Abdominal examination
  • External genitalia examination (check for e.g. phimosis, meatal stenosis)
  • Digital rectal examination (check for inner tone, prostate size/consistency, palpable nodules)
  • Focused neurological examination
  • Urinalysis (UTI/haematuria)
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27
Q

What are the second line investigations for a male patient with lower urinary tract symptoms?

A
  • Flow rates and residual volume
  • Frequency volume chart
  • Renal biochemistry
  • Imaging
  • PSA?
  • TRUSS (transrectal ultrasound)
  • Urodynamics (in some cases)
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28
Q

What are the possible complications of BPH?

A
  • Infections
  • Stones
  • Haematuria
  • Acute retention
  • Chronic retention
  • Interactive obstructive uropathy
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29
Q

How is acute urinary retention treated?

A

Self-catheterisation or bladder outflow surgery

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30
Q

What symptom should alert the clinician to the risk of obstructive uropathy?

A

Nocturnal enuresis

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31
Q

What are the long term treatment options for obstructive uropathy?

A

Surgery (TURP) or indwelling catheter

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32
Q

Name two types of drugs that can be used to treat the symptoms of BPH

A

Alpha-adrenergic antagonists

5-alpha-reductase inhibitors

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33
Q

Name two alpha-adrenergic antagonists

A

Tamsulosin

Doxazosin

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34
Q

How do alpha-adrenergic antagonists help with the symptoms of BPH?

A

Promoting relaxation of the muscles around the prostate and bladder to allow increased flow of urine.

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35
Q

Name two 5-alpha-reductase inhibitors

A

Finasteride

Dutasteride

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36
Q

How do 5-alpha-reductase inhibitors help with the symptoms of BPH?

A

Inhibiting the conversion of testosterone to dihydrotestosterone (more active form), which results in a decrease in prostate size

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37
Q

Why would you normally start a patient on both an alpha-adrenergic antagonist and a 5-alpha-reductase inhibitor and then stop the alpha-adrenergic antagonist after 6-9 months?

A

The alpha-adrenergic antagonist gets to work faster, but only the 5 alpha-reductase-inhibitor will actually prevent symptomatic progression so best to start the AAA alongside the 5ARI until the 5ARI has had a chance to work.

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38
Q

What are the indications for surgery in patients with BPH?

A
  • Bladder stones
  • Recurrent gross haematuria
  • Recurrent infections
  • Therapy failure
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39
Q

What are the early complications of transurethral resection of prostate?

A
  • Bleeding
  • Sepsis
  • Post TUR syndrome
  • Retention (formation of clots inside catheter)
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40
Q

What are the late complications of transurethral resection of prostate?

A
  • Retrograde ejaculation (all patients)
  • Delayed bleeding
  • Urethral stricture
  • Bladder neck contracture
  • Urinary incontinence
  • Erectile dysfunction
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41
Q

What is a neuropathic bladder?

A

A bladder with dysfunctional voiding due to damage to the innervation

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42
Q

What things need to be assessed when investigating neuropathic bladder?

A
  • Underlying cause (e.g. level and completeness of injury in spinal cord injury)
  • Bladder sensation
  • Incontinence (all the time?)
  • Urgency
  • UTI
  • Haematuria
  • Bowel function
  • Sexual function
  • Urinalysis +/- MSU
  • USS renal tracts with post void residual measurement (check for signs of hydronephrosis and completeness of emptying)
  • Flexible cystoscopy (can present with bladder stones)
  • Video urodynamics
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43
Q

How is detrusor pressure calculated in video urodynamics?

A

A pressure transducer in the rectum measures the intra-abdominal pressure and a dual lumen pressure transducer in the bladder measures intra-vesical pressure. Detrusor pressure = intra-abdominal pressure - intra-vesical pressure

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44
Q

What should the detrusor pressure line look line on a urodynamic trace?

A

It should be completely flat until the patient is asked to pass urine and return to normal afterward.

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45
Q

How does a urodynamic study inform about bladder compliance?

A

Bladder compliance is the ability of the bladder to change volume without alteration in detrusor pressure.

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46
Q

Why is detrusor pressure >40 considered a problem?

A

Risks damage to the upper urinary tracts

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47
Q

What is reflex bladder?

A

A type of neuropathic bladder condition whereby the reflex cycle for micturition is intact.

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48
Q

What two issues can occur with reflex bladder?

A
  1. Detrusor overactivity (detrusor contracts when it shouldn’t)
  2. Detrusor-sphincter dyssenergia (sphincter doesn’t open early enough so detrusor keeps contracting until sphincter opens or until pressure overrides sphincter)
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49
Q

What is the main symptom of detrusor overactivity?

A

Urgency

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50
Q

What is the main symptom of detrusor-sphincter dyssynergia?

A

Only passing a small amount of urine

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51
Q

Why is detrusor-sphincter dyssynergia unsafe?

A

Risks upper UT damage

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52
Q

What is an areflexic bladder?

A

An acontractile bladder with no innervation to the detrusor, leading to retention.

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53
Q

Suprapontine lesions can be caused by cerebrovascular accident, dementia, cerebral palsy and brain tumours. What effect will these have on the bladder?

A

The inhibitory effect on the micturition centre will be lost, leading to storage symptoms and urgency etc.

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54
Q

Suprasacral lesions are most commonly caused by spinal cord injury and multiple sclerosis. What effect will these have on the bladder?

A

Micturition reflex is preserved but coordination and inhibition of the reflex is disrupted.

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55
Q

Sacral/infrasacral lesions can be caused by spina bifida, multiple sclerosis and trauma. What effect will these have on the bladder?

A

More likely to result in acontractile bladder. Dysfunction depends on level of the injury and whether complete or incomplete.

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56
Q

What are the 4 treatment options for neurogenic detrusor overactivity?

A
  1. Anticholinergic treatment
  2. Intravesical Botox + intermittent catheterisation
  3. Augmentation cystoplasty
  4. Ileal conduit
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57
Q

What are the 5 treatment options for detrusor sphincter dyssynergia?

A
  1. CISC (clean intermittent self catheterisation)
  2. Suprapubic catheter
  3. Sphincterotomy
  4. Augmentation cystoplasty +/- Mitrofanoff
  5. Ileal conduit
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58
Q

What are the management options for areflexic bladder?

A
  1. CISC (primary)
  2. Suprapubic catheter
  3. Sphincterotomy
  4. Ileal conduit
  5. Autologous fascial sling (if patient has stress incontinence)
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59
Q

What neuropathic bladder treatment is always the last resort and why?

A

Ileal conduit, due to the risk of infection and bleeding

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60
Q

What is autonomic dysreflexia?

A

A potentially life-threatening condition that can occur in patients with spinal cord injury at T6 or higher.
A noxious stimulus (e.g. tight clothing, pressure sore, faecal impaction, blocked catheter/full bladder/UTI) triggers a sympathetic response (tachycardia, sweating, flushing, increased BP, headache). The parasympathetic response is not enough to override the sympathetic response below the level of the injury, so results in vasodilation etc. above the injury but vasoconstriction etc. below the injury.

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61
Q

How is autonomic dysreflexia managed?

A
  1. Sit the patient upright to get gravity on your side
  2. 2 sprays of sublingual GTN to reduce blood pressure
  3. Treat noxious stimulus e.g. remove tight clothing, empty bladder, disimpact bowel
  4. Administer 5-10mg nifedipine if more time required to treat stimulus
  5. Contact anaesthetists - if ongoing assessment required, may require spinal anaesthetic.
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62
Q

What is urinary incontinence?

A

Involuntary loss of urine

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63
Q

What are the common causes of urinary incontinence?

A 
DIAPERS:
Delirium/dementia
Infection
Atrophic vaginitis/urethritis
Pharmaceuticals/psychiatric causes
Endocrine causes
Restricted mobility
Stool impaction
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64
Q

What is overflow incontinence?

A

Caused by retention, occurs as pressure overcomes the sphincter

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65
Q

What is the most common cause of continuous incontinence?

A

Vesico-vaginal fistula

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66
Q

What form is used to work out how severe incontinence is?

A

ICIQ

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67
Q

What should be assessed when taking history for urinary incontinence?

A

Onset, triggers, haematuria, obs and gynae history, past medical history, smoking status, bowel function, sexual function, bladder diary

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68
Q

What should be carried out during examination of a patient who presents with urinary incontinence?

A

Abdominal/pelvic examination, cough test, digital rectal examination, lower limb neurological examination, urinalysis +/- MUS, post void residual scan

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69
Q

What is urge urinary incontinence?

A

Involuntary loss of urine preceded by sudden urgency

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70
Q

What conservative measures can be used to improve the symptoms of urge incontinence?

A

Reducing caffeine intake, spicy foods, citrus drinks, weight loss, smoking cessation, bladder training

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71
Q

What may improve urge incontinence in patients with atrophic vaginitis?

A

Topical oestrogen cream

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72
Q

How do anticholinergic drugs such as oxybutynin and solifenacin reduce the symptoms of urge incontinence?

A

By inhibiting the muscarinic receptors in the detrusor muscle, thereby inhibiting detrusor contraction.

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73
Q

What is the second line pharmacological treatment for urge incontinence?

A

B3 agonists e.g. mirabegron, vibebegron - inhibit detrusor contraction

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74
Q

What is often seen on urodynamics in patients with urge incontinence?

A

‘Bumps’ of detrusor activity

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75
Q

What are the two options for surgical treatment of urge incontinence if pharmacological management is ineffective?

A
  1. Intravesical Botox

2. Sacral neuromodulation

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76
Q

What is stress urinary incontinence?

A

Involuntary loss of urine during activities that increase intra-abdominal pressure

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77
Q

What are the risk factors for stress urinary incontinence?

A

Age, obesity, parity (vaginal delivery, use of forceps), chronic constipation, chronic cough, vaginal prolapse

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78
Q

What is stress urinary incontinence usually caused by?

A

Urethral hypermobility, intrinsic sphincter deficiency or a combination of both

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79
Q

What conservative measures can be used to help with stress incontinence?

A

Lifestyle modifications e.g. smoking cessation, avoiding constipation, weight loss, reduction of caffeine intake
Pelvic floor muscle therapy
Containment e.g. pads, catheterisation

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80
Q

Duloxetine is an SNRI that relaxes the bladder and increases sphincter resistance. However, it is rarely used to treat stress incontinence now. Why?

A

Significant side effects reported by 24% of patients and increased rate of suicide.

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81
Q

What are the invasive treatment options for stress incontinence?

A

Urethral bulking agents
Buch colposuspension
Autologous fascial sling
Synthetic mesh tapes (scandal)

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82
Q

What is the most common cause of stress urinary incontinence in males?

A

Prostatectomy (can also be caused by TURP, pelvic radiotherapy and pelvic surgery)

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83
Q

How is male stress urinary incontinence treated?

A

Initially with pelvic floor muscle training

Gold standard management is an artificial urinary sphincter

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84
Q

What type of renal carcinoma is the most common?

A

Renal cell carcinoma

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85
Q

Other than renal cell carcinoma, what are two other types of kidney cancer?

A

Transitional cell carcinoma

Squamous cell carcinoma (very rare)

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86
Q

What can cause nephroblastoma in children?

A

Wilm’s tumour

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87
Q

Name two types of benign renal masses

A
  1. Oncocytoma

2. Angiomyolipoma

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88
Q

What type of cancer is renal cell carcinoma?

A

Adenocarcinoma

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89
Q

What are the risk factors for renal cell carcinoma?

A

Smoking, obesity, renal failure, hypertension, social deprivation

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90
Q

Where does renal cell carcinoma often metastasise to?

A

Lungs - ‘cannon ball’ metastases, also local invasion (blood vessels, adrenal gland).

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91
Q

How does renal cell carcinoma present?

A 
Most found incidentally (asymptomatic)
Can present with:
Haematuria
Loin pain
Palpable mass
Systemic symptoms e.g. fatigue, weight loss, bone pain etc.
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92
Q

Paraneoplastic syndromes are weird bodily effects caused by cancer. What are some of the effects?

A

Anaemia, polycythaemia, hypertension, hypercalcaemia, hypoglycaemia, Stauffer’s syndrome

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93
Q

What investigations should be carried out for suspected renal cell carcinoma?

A

FBC, U&E, LFT, coagulation
CT scan
Needle biopsy may be required to confirm diagnosis but if the tumour is large, should be operated on regardless

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94
Q

What is the gold standard treatment for small tumours confined to the kidney?

A

Partial nephrectomy

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95
Q

Why should renal cell carcinoma not be treated with radiotherapy?

A

Renal cell carcinoma is not radiosensitive

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96
Q

What is the operation for upper tract transitional cell carcinoma?

A

Nephroureterectomy - have to take out the entire ureter and maybe even part of the bladder too to avoid recurrence

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97
Q

What is the most common type of bladder cancer in the UK?

A

Transitional cell carcinoma

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98
Q

What is the most common type of bladder cancer in Egypt and why?

A

Squamous cell carcinoma due to endemic schistosomiasis

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99
Q

What are the risk factors for bladder cancer?

A

Smoking, dyes, carcinogens, PAHs, diesel exhaust, industrial exposure (leather workers, drivers, hairdressers), drugs (phenacetin, cyclophosphamide, pioglitazone)

100
Q

What are the 4 stages of transitional cell carcinoma?

A

T1 - non-invasive/subepithelial only (low risk)
T2 - muscle invasive
T3 - through the muscle, invading perivesical fat
T4 - invading prostate/pelvic side wall (lethal)

101
Q

To where does transitional cell carcinoma tend to metastasise?

A

Liver, lungs, bone, adrenal glands

102
Q

How does bladder cancer normally present?

A

Painless visible haematuria with lower urinary tract symptoms (frequency/urgency/nocturia/recurrent UTI), may be palpable mass in lower abdomen (abdominal examination/DRE)

103
Q

What procedure can be used to investigate the cause of haematuria?

A

Flexible cystoscopy

104
Q

Why is USS KUB more likely to be performed than CT urogram even though it’s less sensitive for the upper tract?

A

Safety - CT urogram requires a lot of radiation and contrast

105
Q

What are the common urological causes of non-visible haematuria?

A

BPH, cancer (bladder, kidney, prostate), stone disease, infection (haemorrhagic cystitis)

106
Q

What are the possible nephrological causes of non-visible haematuria?

A

IgA nephropathy, thin basement membrane disease, glomerulonephritis, vasculitis, Henoch-Schoenlein purpura

107
Q

What is the standard surgical treatment for non-invasive bladder cancer?

A

TURBT - transurethral resection of bladder tumour

108
Q

What are two intravesical therapies for bladder cancer?

A
  1. Mitomicin C (chemo)

2. BCG

109
Q

What can be used to treat muscle invasive bladder cancer?

A

Radical surgery (cystoprostatectomy/cystourethrectomy and lymphadenectomy) with diversion/reconstruction e.g. ileal conduit + chemotherapy (neoadjuvant or adjuvant)

Radiotherapy for patients unfit for surgery/palliative care

110
Q

What is the most common solid cancer in men aged 20-45?

A

Testicular cancer

111
Q

How does testicular cancer normally present?

A

Usually with a painless lump

Some present with symptoms suggestive of advanced disease

112
Q

What investigations should be carried out for suspected testicular cancer?

A 
Scrotal USS
Tumour markers (AFP, beta-HCG, LDH)
Chest x-ray, CT scan abdomen and pelvis +/- chest
113
Q

How is testicular cancer managed?

A

Radical inguinal orchidectomy
Chemotherapy (very sensitive to platinum based chemo)
Retroperitoneal lymph node dissection

114
Q

Name 8 functions of the kidney

A
  1. Waste excretion
  2. Electrolyte balance
  3. ECF volume regulation
  4. Blood pressure regulation
  5. Acid-base balance
  6. PTH target
  7. Red blood cell numbers (EPO)
  8. Gluconeogenesis promotion (late response)
115
Q

What are the two types of nephrons in the kidney?

A
  1. Cortical nephrons - short loops, glomeruli in outer cortex
  2. Juxtamedullary nephrons - glomeruli border on medulla, long loops, paired with vasa recta
116
Q

What are the two capillary beds in the kidney?

A
  1. Glomerulus (high hydrostatic pressure, rapid fluid filtration)
  2. Peritubular capillaries (lower hydrostatic pressure, rapid fluid reabsorption)
117
Q

What is the vasa recta?

A

Specialised blood supply around the juxtamedullary nephrons supplying the counter current blood flow around the loop of Henle.

118
Q

What effects does changing afferent and efferent arteriolar resistance in the kidney?

A
  1. Modifies hydrostatic pressure in the capillary beds

2. Alters glomerular filtration rate, tubular reabsorption or both

119
Q

What three things influence the glomerular filtration rate?

A
  1. Net filtration pressure (derived from hydrostatic pressures and colloid osmotic pressures)
  2. Renal blood flow
  3. Filtration coefficient Kf (measure of how well the membrane structure is filtering)
120
Q

What forces move fluid out at the glomerulus?

A
  1. Capillary pressure

2. Interstitial fluid colloid and oncotic pressure

121
Q

What forces move fluid in at the glomerulus?

A
  1. Plasma colloid oncotic pressure (from albumin)

2. Interstitial fluid pressure

122
Q

How is net filtration pressure calculated?

A

Glomerular hydrostatic pressure - (capsular hydrostatic pressure + blood colloid osmotic pressure)

123
Q

Describe how tubuloglomerular feedback works to restore a drop in glomerular filtration rate.

A

Macula densa cells (between the afferent and efferent arterioles) sense a decrease in NaCl, secrete prostaglandins, afferent arteriole dilates, increasing blood flow and restores GFR
Also, juxtaglomerular cells release renin, activates RAAS pathway, angiotensin II causes vasoconstriction at efferent arteriole, which also increases GFR.

124
Q

Why should NSAIDs not be used by patients with renal impairment?

A

NSAIDs inhibit prostaglandin synthesis, which interferes with the tubuloglomerular feedback mechanism.

125
Q

What is the minimum estimated GFR that a person should have?

126
Q

Name two drugs that inhibit tubular secretion of creatinine

A

Cimetidine, trimethoprim

127
Q

What is creatinine and why is it used to estimate glomerular filtration rate?

A

Creatinine is a waste product made by the muscles. It is normally filtered out of the blood by the kidneys. Therefore, if serum creatinine levels are high, this can indicate poor filtration by the kidneys.

128
Q

Name three things that decrease GFR by decreasing Kf

A
  1. Renal disease
  2. Diabetes mellitus
  3. Hypertension
129
Q

How do the kidneys regulate ECF volume?

A

Increased blood volume results in increased blood pressure. The kidneys respond by increasing renal excretion and normal volume is restored.

130
Q

What is atrial natriuretic peptide and what effect does it have on the kidney?

A

ANP is secreted by the heart in response to atrial stretch as a result of high blood pressure. It triggers dilation of the afferent arteriole to increase GFR and also inhibits renin secretion, leading to a subsequent decrease in angiotensin II and aldosterone secretion, a decrease in sodium reabsorption, increase in water secretion, increase in diuresis and a decrease in ECF volume.

131
Q

What is chronic kidney disease?

A

Abnormalities of kidney structure or function, present for over three months, with implications for health.
Abnormal function defined as eGFR < 60ml/min/1.73m2 or albuminuria (urine albumin creatinine ratio > 3mg/mmol)
Abnormal structure as seen on histology or radiology

132
Q

What is used to determine the level of proteinuria?

A

Albumin creatinine ratio

133
Q

How do patients with chronic kidney disease usually present?

A

Usually asymptomatic, found incidentally through screening of patients with comorbidities.
Occasionally presents with unexplained haematuria or oedema

134
Q

Name 6 of the more common causes of chronic kidney disease

A
  1. Diabetes
  2. Chronic glomerulonephritis
  3. Cystic disease
  4. AKI
  5. Obstructive uropathy
  6. Hypertension
135
Q

Name two non-modifiable risk factors for progression of chronic kidney disease.

A
  1. Race

2. Underlying cause of renal disease

136
Q

Name some modifiable risk factors for progression of chronic kidney disease.

A
  1. Blood pressure
  2. Level of proteinuria (can use ACE inhibitors)
  3. Exposure to nephrotoxins (e.g. medications)
  4. Underlying disease activity
  5. Further renal insults
  6. Dyslipidaemia (treat with statins)
  7. Increased phosphate
  8. Acidosis
  9. Anaemia
  10. Smoking
  11. Glycaemic control if diabetic
137
Q

How many CKD stages are there?

138
Q

At what stage of CKD would discussion start regarding the options of haemodialysis, peritoneal dialysis and transplantation?

139
Q

At what point would a patient be sent to the renal clearance clinic to start preparing for renal replacement therapy/transplant?

140
Q

What drugs can be used to treat CKD?

A

Diuretics to treat salt and water retention

Sodium binders to bind sodium in the gut

141
Q

Why is dialysis not a perfect physiological replacement for a kidney?

A

It cannot activate vitamin D, produce erythropoietin or allow complete physiological correction.

142
Q

What is glomerulonephritis?

A

A broad term that refers to a group of parenchymal kidney diseases that cause inflammation and damage to the glomeruli

143
Q

How can we tell if podocytes aren’t working properly?

A

Protein ends up in the urine

144
Q

What three things can be caused by glomerulonephritis?

A
  1. Leaky glomeruli, resulting in haematuria and proteinuria
  2. High blood pressure
  3. Deteriorating kidney function
145
Q

Name 6 different presentations of glomerulonephritis.

A
  1. Acute nephritic syndrome
  2. Nephrotic syndrome
  3. Asymptomatic urinary abnormalities
  4. Chronic glomerulonephritis
  5. Macroscopic haematuria
  6. Nephritic syndrome
146
Q

What are the clinical features of acute nephritic syndrome?

A
  1. Rapid deterioration in kidney function
  2. Haematuria and proteinuria on urine dipstick
  3. Oliguria, hypertension and fluid overload
147
Q

Name 5 causes of acute nephritic syndrome

A
  1. ANCA associated vasculitis
  2. Goodpastures disease (anti-glomerular basement membrane antibodies)
  3. Autoimmune: SLE/systemic sclerosis
  4. Post-streptococcal infection
  5. Crescentic IgA nephropathy/Henoch Schonlein purpura
148
Q

What might you see on fundoscopy of a person with acute nephritic syndrome?

A

Flame haemorrhages on retina due to bleeding as a result of hypertension.

149
Q

What is (non-acute) nephritic syndrome?

A

Part of a systemic disease - ANCA associated vasculitis

150
Q

Who is most likely to have nephritic syndrome?

A

Caucasians aged 50-70

151
Q

How is nephritic syndrome diagnosed?

A

Systemic inflammatory features with evidence of other organ involvement
ANCA positive
Biopsy shows segmental glomerular necrosis with crescent formation, active lesions, fibrosis and tubular atrophy

152
Q

How is nephritic syndrome treated?

A

Immunosuppression with steroids and cyclophosphamide to start with, maintenance with azathioprine/rituximab.

153
Q

What is IgA nephropathy?

A

Nephropathy caused by build-up of IgA deposits in the kidneys, which results in local inflammation.

154
Q

How does IgA nephropathy usually present?

A

Episodic macroscopic haematuria, usually in 20s-30s, many cases identified as a result of asymptomatic urine testing.

155
Q

How is IgA nephropathy diagnosed?

A

Biopsy - will show diffuse mesangial IgA deposits, sometimes subendothelial and subepithelial deposits can be seen on electron microscopy.

156
Q

How is IgA nephropathy treated?

A 
Supportive care (BP control with RAAS inhibitors, diet, lower cholesterol)
Immunosuppression with steroids, cyclophosphamide and maintenance with azathioprine.
157
Q

What is lupus nephritis?

A

Inflammation of the kidney caused by systemic lupus erythematosus

158
Q

How is lupus diagnosed?

A

AMA antibody test

159
Q

Proliferative lupus nephritis is the most severe type. How is it treated?

A

Steroids, cyclophosphamide for 3 months followed by azathioprine.

160
Q

How is membranous lupus nephritis treated?

A

Supportive care, steroids and possibly cyclophosphamide and azathioprine, but evidence for this is weak.

161
Q

What is nephrotic syndrome?

A

A condition that causes the kidneys to leak large amounts of protein into the urine.

162
Q

What are the features of nephrotic syndrome?

A 
Heavy proteinuria
Hypoalbuminaemia
Oedema
Hypercholesterolaemia
Frothy urine
Swollen ankles
163
Q

What is almost always the cause of nephrotic syndrome in children?

A

Minimal change nephropathy

164
Q

Name 3 primary causes of nephrotic syndrome (i.e. podocyte disease)

A
  1. Minimal change nephropathy
  2. Membranous nephropathy
  3. Focal segmental glomerulosclerosis
165
Q

Name 7 secondary causes of nephrotic syndrome

A
  1. Diabetes
  2. Amyloidosis
  3. Infection
  4. SLE
  5. Drugs
  6. Malignancy
  7. Scarring
166
Q

How is nephrotic syndrome managed?

A
  1. Establish cause (usually with renal biopsy in adults)
  2. Treat complications and manage fluid state (diuretics, ACEI/ARBs, spironolactone)
  3. Treat underlying cause
167
Q

What investigations need to be carried out for nephrotic syndrome?

A

Renal biopsy + investigations to establish underlying cause:
Serum albumin, creatinine, lipids and glucose, urinalysis
Urine protein creatinine ratio (quantify proteinuria)
ANA, DNA antibody, C3 and C4 (lupus)
Antiphospholipase A2 receptor antibody (membranous)
HepBsAg, HepCAb to diagnose Hep B/C associated glomerular disease

168
Q

What happens in membranous glomerulonephritis?

A

The glomerular capillary wall thickens and IgG and complement deposits in subepithelial surface, resulting in a leaky glomerulus.

169
Q

How is membranous glomerulonephritis diagnosed?

A

Serum PLA2R antibody ( present in most cases) + renal biopsy

170
Q

How is membranous glomerulonephritis managed?

A

Mostly supportive treatment - nearly 50% of patients will recover with only blood pressure treatment
Control of oedema, hypertension, hyperlipidaemia and proteinuria
May require immunosuppression with steroids and cyclophosphamide.

171
Q

How is minimal change disease diagnosed?

A

Renal biopsy appears normal but fused podocytes on electron microscopy.
Don’t need to perform biopsy in children because any presentation of nephrotic syndrome is almost certainly minimal change disease.

172
Q

Describe the natural history of minimal change disease.

A

It has a relapsing-remitting course, but does not progress to renal failure.

173
Q

How is minimal change disease managed?

A

First line treatment: steroids
Second line treatment: cyclophosphamide/cyclosporine
Some evidence for rituximab

174
Q

What are the three types of pathophysiology that cause erectile dysfunction?

A
  1. Neurogenic = failure to initiate
  2. Arteriogenic = failure to fill
  3. Venogenic = failure to store
175
Q

Name 8 causes of erectile dysfunction

A
  1. Age
  2. Diabetes
  3. Coronary artery disease
  4. Dyslipidaemia
  5. Hypogonadism
  6. Trauma
  7. Drugs
  8. Psychosomatic causes
176
Q

What needs to be checked when assessing a patient with erectile dysfunction?

A
  • Height, weight, BMI
  • Thyroid function, pulmonary function, cardiac rhythm
  • Abdominal examination and mid-waist circumference
  • Penoscrotal examination
  • Rectal examination (if indicated)
177
Q

What tests should be requested when investigating erectile dysfunction?

A
  • Urinalysis (check for infection)
  • Fasting blood glucose and lipids
  • Total testosterone
  • PSA
  • Prolactin
  • Scan to check blood supply (Rigiscan)
178
Q

What drugs are given to treat erectile dysfunction?

A

PDE-5 inhibitors, can be given as tablets, injections, suppositories or implants.

179
Q

How do PDE-5 inhibitors work?

A

Inhibiting cGMP, which would normally inhibit vasodilation. This allows blood flow to the penis.

180
Q

Give two examples of PDE-5 inhibitors

A

Sildenafil

Tadalafil

181
Q

What devices can be used to treat erectile dysfunction?

A

Vacuum-assisted device (requires good vasculature in shaft of penis to be effective)
Implant (reservoir balloon in abdomen, fluid flows from reservoir to penis when button pressed)

182
Q

What sort of cancer is prostate cancer?

A

Adenocarcinoma (as prostate is a gland)

183
Q

Where does prostate cancer tend to metastasise to?

A

Lymph nodes and bone (most common)

Occasionally to lung, liver and brain

184
Q

What tests should be requested for suspected prostate cancer?

A

Biopsy (definitive)
Serum test: PSA, PSMA (prostate-specific membrane antigen)
Urine test: PCA3, gene fusion products (TMPRSS2-ERG), EN2 protein

185
Q

What is PSA?

A

Prostate-specific antigen, a serine protease responsible for liquefaction of semen

186
Q

Why would PSA be found in the blood?

A

Due to retrograde leakage

187
Q

How are PSA levels used to help diagnose prostate cancer?

A

Elevated PSA level not diagnostic of cancer on its own, can be elevated in BPE, UTI and prostatitis. However, the higher the PSA level, the higher the chance of cancer.

188
Q

What system is used to grade prostate histology specimens based on tissue architecture?

A

Gleason grading, group 1-5

189
Q

What is TNM staging, with regard to prostate cancer?

A 
T = tumour, grade 1-3
T1 = no palpable tumour
T2 = palpable tumour, confined to prostate
T3 = palpable tumour, extending beyond prostate

N = nodal (MRI/CT scan)

M = metastatic (bone/PET/MRI scan)

–> Localised/locally advanced/metastatic

190
Q

How is localised prostate cancer treated?

A

Observation or proceed to curative treatment (surgery, radiotherapy, adjuvant hormone therapy)

191
Q

How is locally advanced prostate cancer treated?

A

Surgery, radiotherapy and adjuvant hormone therapy

192
Q

How is metastatic prostate cancer treated?

A

Palliative hormone therapy

193
Q

What are the three types of urinary tract infection?

A
  1. Asymptomatic bacteriuria
  2. Uncomplicated
  3. Complicated
194
Q

What is pyuria?

A

The presence of leukocytes in the urine

195
Q

Asymptomatic bacteriuria is always present in which group of patients?

A

Those who are catheterised

196
Q

What is the difference between complicated and uncomplicated UTI?

A

Uncomplicated UTI occurs in non-pregnant women

UTI in any other demographic is considered complicated.

197
Q

Which patients are at particularly high risk of progression of UTI to pyelonephritis?

A

Renal transplant patients

198
Q

Which pathogen causes >50% of UTIs?

199
Q

What pathogen that sometimes causes UTI is associated with renal stones?

A

Proteus (produces urease –> stone formation)

200
Q

What pathogen that sometimes causes UTI is associated with hospital/catheterisation?

A

Klebsiella

201
Q

What organism can indicate a deep seated infection if found in the urinary tract?

A

Staph aureus

202
Q

What organism can cause recurrent UTIs and may suggest underlying pathology?

A

Pseudomonas aeruginosa

203
Q

Why are females more likely to get UTIs?

A

A shorter urethra means that flora from the bowel are more likely to get in

204
Q

Why is prostate enlargement sometimes associated with UTIs?

A

Prostate enlargement causes urine stasis

205
Q

What are the main symptoms of a lower UTI?

A

Frequency

Dysuria

206
Q

What are the main symptoms of an upper UTI?

A

Haematuria

Pyrexia

207
Q

What tests can be used to diagnose UTI?

A

Urine dipstick

Microscopy, culture and sensitivities

208
Q

What 7 things does urinalysis look at?

A
  1. Blood
  2. Protein
  3. pH
  4. Glucose
  5. Ketones
  6. Nitrates
  7. Leukocytes
209
Q

What things on urinalysis are seen as evidence of infection?

A

Presence of leukocytes and protein

210
Q

What are ‘casts’ seen on urine microscopy?

A

Formed in renal tubules, may indicate pyelonephritis/glomerulonephritis

211
Q

What does it mean if epithelial cells are seen on urine microscopy?

A

The specimen was likely poorly taken.

212
Q

Which patients should not be treated if they have asymptomatic bacteriuria?

A

Those over 65 - these patients are unlikely to develop pyelonephritis and giving antibiotics leads to increased antibiotic resistance.

213
Q

Which antibiotic is normally given as a first line treatment for a UTI?

A

Nitrofurantoin

214
Q

In which patients is nitrofurantoin contraindicated?

A
  • Patients in 3rd trimester of pregnancy

- Patients with poor renal function

215
Q

Why is nitrofurantoin generally preferable to trimethoprim?

A

30% of E coli UTIs are resistant to trimethoprim

216
Q

Which new antibiotics can be given to treat UTIs in the case of resistance to nitrofurantoin?

A

Fosfomycin

Pivmecillinam

217
Q

How should UTIs in pregnant women be managed?

A
  • Screening should be offered in pregnancy
  • Urine culture rather than dipstick
  • Positive cultures should be confirmed with second sample
  • Asymptomatic bacteriuria should be treated due to risk of pyelonephritis
  • Test of cure should be sent 1 week after treatment
218
Q

What is pyelonephritis?

A

Infection of the renal parenchyma and soft tissues of renal pelvis/upper ureter

219
Q

Which demographic is most at risk of pyelonephritis?

A

Women < 35

220
Q

How is pyelonephritis investigated?

A

Abdominal examination (loin tenderness, renal angle tenderness)
Bloods including cultures
USS to rule out upper tract obstruction
MSU

221
Q

How is pyelonephritis treated?

A 
Fluid replacement
IV antibiotics (broad spectrum e.g. co-amoxiclav +/- gentamicin) 7-14 days
Drain obstructed kidney
Catheter
Analgesia
222
Q

What are the potential complications of pyelonephritis?

A 
Renal abscess (more common in diabetics)
Emphysematous pyelonephritis (rare - gas accumulation in tissues, life threatening, may require nephrectomy)
223
Q

Where can urinary stones occur?

A

Anywhere in the urinary tract - kidneys, ureters, bladder, prostate, urethra

224
Q

Name some congenital factors that can increase the likelihood of developing stones.

A

Horseshoe kidney
Duplex kidney
Spina bifida

225
Q

Name some acquired anatomical factors that can increase the likelihood of developing stones.

A

Obstruction
Trauma
Reflux

226
Q

What urinary factors increase the likelihood of developing stones?

A
  • Too much of a particular salt present in the urine (metastable urine)
  • Dehydration
  • Infection (some UTIs are more commonly associated with infection)
227
Q

In the UK, what are most urinary stones comprised of?

A

80% are calcium-based

228
Q

What steps can be taken to prevent urinary stones?

A 
Adequate hydration
Low sodium diet
Normal dairy intake (low calcium intake does not decrease stone formation)
Moderate protein intake
Maintain normal BMI
Active lifestyle
229
Q

What kind of stones can form as a result of congenital disease?

A

Cystine stones as a result of cystinuria

230
Q

What drugs can be given to treat cystinuria?

A

Cystine binders:
Captopril
Penicillamine

231
Q

What symptoms do urinary stones typically cause?

A

May be asymptomatic - many are picked up incidentally
Loin pain
Renal colic (sudden acute severe pain in back/side, which radiates to the lower abdomen, nausea and vomiting)
UTI symptoms (urgency, frequency, dysuria)
Haematuria

232
Q

Why is it a bad idea to drink a lot with urinary stones characterised by renal colic?

A

The fluid doesn’t ‘flush’ the stone through, it just increases fluid build-up.

233
Q

How should renal colic be investigated?

A
  • ABC
  • Give analgesia (diclofenac suppository), antiemetic if required
  • Focused history and examination
  • Urinalysis (MSU if positive)
  • FBC, U&E, calcium, uric acid
  • Imaging - non-contrast CT KUB (normal first line)/KUB x-ray (limited use)
234
Q

What are the possible differential diagnoses for presentation with renal colic?

A
  • Vascular accident: assume ruptured abdominal aortic aneurysm until proven otherwise
  • Bowel pathology e.g. diverticulitis, appendicitis
  • Gynaecological e.g. ectopic pregnancy, ovarian cyst, torsion
  • Testicular torsion
  • Musculoskeletal issues
235
Q

Why is non-contrast CT preferred to x-ray when investigating urinary stones?

A

Only 50-60% show up on x-ray, whereas nearly all will show up on CT.
CT also more likely to show other kinds of pathology.

236
Q

What are the problems with CT when investigating stones?

A

High radiation dose

Does not give any functional information about the kidneys

237
Q

How is the NCCT KUB interpreted?

A
  1. Count the kidneys - if two are present, can be more relaxed about how one of them is functioning.
  2. Condition of the kidneys - perinephric tissues, cortical thickness, hydronephrosis/hydroureter, stones
  3. Look for evidence of any other pathology
238
Q

What’s the best analgesic to give a patient with ureteric colic if they can’t have NSAIDs?

A

IV paracetamol

239
Q

What is pyonephrosis?

A

A combination of obstruction and infection - can be rapidly fatal

240
Q

How is pyonephrosis treated?

A

IV antibiotics
Oxygen
Drainage (nephrostomy/ureteric stent)

241
Q

How would a ureteric stone <5mm normally be managed?

A

Providing patient is well, with adequate pain control, management normally conservative - give 2 weeks to pass.

242
Q

How would a ureteric stone 5-10mm normally be managed?

A

ESLW (lithotripsy)

243
Q

How are small renal stones (<1cm) managed?

A

Conservative management if they are in a safe location, static size and asymptomatic.

244
Q

What are the treatment options for renal stones measuring 1-2cm?

A

ESWL (extracorporeal shockwave lithotripsy)

Flexible ureteroscopy with laser

245
Q

What treatment would be used for larger renal stones >2cm?

A

PCNL (keyhole surgery)

percutaneous nephrolithotomy

246
Q

How are bladder stones normally treated?

A

Normally conservative management
Possible endoscopic treatment
Larger stones can be treated via open/laparoscopic surgery

Phase 2a Medicine (13 decks)

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