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Urology Flashcards

1
Q

Describe obstructive uropathy

A

Back-pressure in the urinary system causing areas proximal to the obstruction to become swollen with urine

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2
Q

Describe the presentation of an upper urinary tract obstruction

A

Loin to groin/flank pain on affected side - irritation and stretching of the ureter and kidney
Reduced or no urine output
Non-specific systemic symptoms - vomiting
Impaired renal function on blood tests

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3
Q

Describe the presentation of a lower urinary tract obstruction

A

Difficulty or inability to pass urine - poor flow, difficulty initiating urination or terminal dribbling
Urinary retention - increasingly full bladder
Impaired renal function on blood tests - raised Cr

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4
Q

What investigation is used to diagnose obstructive uropathy

A

Ultrasound KUB

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5
Q

List some causes of upper urinary tract obstruction

A 
Kidney stones
Tumours pressing on ureters
Ureteric stricture
Retroperitoneal fibrosis
Bladder cancer 
Ureterocoele
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6
Q

List some causes of lower urinary tract obstruction

A 
Benign prostatic hyperplasia
Prostate cancer
Bladder cancer
Urethral strictures
Neurogenic bladder
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7
Q

Describe a neurogenic bladder

A

Abnormal function of the nerves innervating the bladder and urethra
Overactivity or underactivity in the detrusor muscle of the bladder and the sphincter muscles of the urethra

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8
Q

List some causes of neurogenic bladder

A 
Multiple sclerosis
Diabetes
Stroke
Parkinson's disease
Brain or spinal cord injury 
Spina bifida
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9
Q

List the complications of neurogenic bladder

A

Urge incontinence
Increased bladder pressure
Obstructive uropathy

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10
Q

Describe the management of obstructive uropathy

A

Nephrostomy - bypass the obstruction in upper urinary tract - drain through skin

Urethral or suprapubic catheter - bypass obstruction in lower urinary tract

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11
Q

List some complications of obstructive uropathy

A 
Pain
AKI - post renal 
CKD
Infection
Hydro nephrosis
Urinary retention and bladder distension
Overflow incontinence of urine
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12
Q

Describe hydronephrosis

A

Swelling of the renal pelvis and calyces in the kidney

Obstruction of the urinary tract causing back pressure into the kidneys

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13
Q

What is idiopathic hydroneprhosis

A

Narrowing at the pelviureteric junction
The site where the renal pelvis becomes the ureter
May be congenital or may develop later
Treated with operation - pyeloplasty

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14
Q

List some features of hydronephrosis on presentation

A

Vague renal angle tenderness

Mass in kidney area

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15
Q

How is hydronephrosis diagnosed

A

Ultrasound, CT or IV urogram

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16
Q

How is hydronephrosis treated?

A

Treat underlying cause
Percutaneous nephrostomy - tube through skin and kidney into the ureter
Anterograde ureteric stent

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17
Q

How would you treat acute urinary retention in a man with an enlarged prostate

A

Insert a catheter
Start Tamsulosin
Discharge to have a trial without a catheter (TWOC) in the community

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18
Q

What type of drug is Tamsulosin

A

Alpha blocker

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19
Q

What are some side effects of Tamsulosin

A

Postural hypotension - Dizziness on standing

Falls

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20
Q

Describe a TWOC

A

Trial without a catheter - remove the catheter to see if the patient can manage without it
Urine output is monitored and a bladder scan is used to make sure there is minimal residual urine left in the bladder

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21
Q

Describe the treatment of catheter-associated urinary tract infections

A

Patients with asymptomatic bacteriuria require no antibiotics

Patients with symptoms require treatment with 7 days of antibiotics. Depending on severity of symptoms this may be with oral antibiotics or require admission to hospital and IV antibiotics. The catheter should be changed as soon as possible

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22
Q

Describe benign prostatic hyperplasia

A

Benign hyperplasia of the stromal and epithelial cells in the prostate leading to enlargement
Common in men >50yo

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23
Q

Describe the presentation of BPH

A

Lower urinary tract symptoms

  • Hesitancy
  • Weak flow
  • Urgency
  • Frequency - small amounts frequently
  • Straining
  • Terminal dribbling
  • Incomplete emptying
  • Nocturia
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24
Q

What is a scoring system used to assess the severity of lower urinary tract symptoms

A

International prostate symptom score

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25
How are men with lower urinary tract symptoms asseesd
Digital rectal examination - size, shape and characteristics of the prostate Abdominal examination - palpable bladder Urinary frequency volume chart - 3 days of fluid intake and output Urine dipstick - blood PSA
26
List some causes of a raised PSA
``` Prostate cancer Benign prostatic hyperplasia Prostatitis Urinary tract infections Vigorous exercise Recent ejaculation or prostate stimulation (DRE) ```
27
Describe the differences between a benign and a cancerous prostate on DRE
Benign - smooth, symmetrical and slightly soft with maintained central sulcus Cancerous - feel firm/hard, asymmetrical, craggy or irregular with loss of the central sulcus
28
Describe the management of BPH
Alpha blockers - Tamsulosin to relax the smooth muscle 5-alpha reductase inhibitors (finasteride) - gradually reduce the size of the prostate Surgery - TURP (transurethral resection of the prostate) Transurethral electro vaporisation of the prostate (TEVAP/TUVP) Holmium laser enucleation (HoLEP) Open proctectomy - abdominal or perineal incision
29
Describe the mechanism of action of 5-alpha reductase inhibitors
5-alpha reductase usually converts testosterone to dihydrotestosterone (DHT) which is a more potent androgen hormone Inhibitors of 5-alpha reductase reduce DHT in the tissues, leading to a reduction in prostate size Usually takes 6 months of treatment for the effects to improve the symptoms
30
List a common side effect of finasteride
Sexual dysfunction
31
Describe transurethral resection of the prostate
Remove part of the prostate from inside the urethra using a retroscope and diathermy loop used to remove prostate tissue Aim is to create a more expansive space for urine to flow through, thereby improving the symptoms
32
List the major complications of TURP
``` Bleeding Infection Urinary incontinence Erectile dysfunction Retrograde ejaculation Urethral strictures Failure to resolve symptoms ```
33
What are the different types of prostatitis
Acute bacterial prostatitis - acute infection in the prostate with more rapid symptoms Chronic prostatitis (>3months) - chronic prostatitis/chronic pelvic pain syndrome (no infection) or chronic bacterial prostatitis (infection)
34
Describe the presentation of chronic prostatitis
Pelvic pain - perineum, testicles, scrotum, penis, rectum, groin, lower back or suprapubic area Lower urinary tract symptoms - dysuria, hesitancy, frequency and retention Sexual dysfunction - erectile dysfunction, pain on ejaculation and haematospermia Pain with bowel movements Tender and enlarged prostate on examination
35
Describe the presentation of acute bacterial prostatitis
More acute presentation of similar symptoms to chronic prostatitis May also be systemic symptoms too - malaise, fever, myalgia, nausea, fatigue and sepsis
36
What investigations should be done for prostatitis
Urine dipstick testing Urine microscopy, culture and sensitives (MC&S) Chlamydia and gonorrhoea (NAAT) testing - 1st pass urine if STI considered
37
Describe the management of acute bacterial prostatitis
Hospital admission if systemically unwell Oral antibiotics - 2-4weeks Analgesia Laxatives
38
Describe the management of chronic prostatitis
Alpha blockers - Tamsulosin - relax smooth muscle with rapid improvement of symptoms Analgesia Psychological treatment - CBT/Antidepressants Antibiotics Laxatives
39
List the complications of acute bacterial peritonitis
Sepsis Prostate abscess - felt as a fluctuant mass and requires surgical drainage Acute urinary retention Chronic prostatitis
40
Where does advanced prostate cancer spread?
Bones and lymph nodes
41
What do most prostate cancers rely on for growth?
Androgens
42
What type of cancer are most prostate cancers?
Adenocarcinomas
43
List some risk factors for prostate cancer
``` Age FH African or caribbean origin Tall stature Anabolic steroids ```
44
Describe the presentation of prostate cancer
Asymptomatic or lower urinary tract symptoms - hesitancy, frequency, weak flow, terminal dribbling and Nocturia Haematuria ED Symptoms of advanced disease - weight loss, bone pain, cauda equina
45
Where is PSA released from
Prostate epithelial cells into the semen with a small amount entering the blood
46
What may an inflamed prostate feel like on examination
Warm, tender and enlarged
47
Describe multiparametric MRI for prostate cancer
1st line investigation for suspected localised Prostate cancer ``` results reported on a Likert scale 1- very low suspicion 2 - low suspicion 3 - equivocal 4- probable cancer 5 - definitive cancer ```
48
Describe a prostate biopsy
If Likert >3 from MRI Risk of false negative if sample wrong area so MRI is used to focus the biopsies Transrectal ultrasound guided biopsy or trans perineal biopsy
49
What are the main risks of prostate biopsy
``` Pain Bleeding Infection Urinary retention Erectile dysfunction ```
50
Describe isotope bone scan in prostate cancer
Radioactive isotope given by IV injection, short wait (2-3hrs) to allow the bones to take up the isotope. A gamma camera is used to take pictures of the entire skeleton Metastatic lesions take up more isotopes making them stand out on scan
51
Describe the Gleason grading system
Based on histology 2 numbers added together 1st number - grade of the most prevalent pattern in the biopsy 2nd number is the grade of the second most prevalent pattern in the biopsy 6 - low risk 7 - Intermediate risk - 4+3 then this is a higher risk than 3+4 >8 - high risk
52
Describe the TNM staging system for prostate cancer
Tumour - Tx - T4 Nodes - Nx-N1 Metastasis M0-M1
53
Describe the management of prostate cancer
MDT Surveillance/watchful waiting in early disease External beam radiotherapy Brachytherapy Hormone therapy Surgery - radical prostatectomy
54
List a complication of external beam radiotherapy
Proctitis - inflammation of the rectum - pain, altered bowel habit, rectal bleeding and discharge
55
What can be given to reduce proctitis
Prednisolone suppositories
56
Describe brachytherapy
Implanting radioactive metal seeds into the prostate Delivers continuous, targeted radiotherapy to the prostate causing inflammation in nearby organs such as bladder or rectum
57
What the symptoms of complications of brachytherapy
ED Incontinence Bladder or rectal cancer
58
Describe hormone therapy for prostate cancer
Reduce the level of androgens that stimulate the cancer to grow Used in combination with radiotherapy or alone in advanced disease for palliation
59
What are the different types of hormone therapy for prostate cancer
Androgen receptor blockers - bicalutamide GnRH agonists - goserelin (zoladex) or leuprorelin (prostap) Bilateral orchidectomy - rarely used
60
List the side effects of hormone therapy for prostate cancer
``` Hot flushes Sexual dysfunction Gynaecomastia Fatigue Osteoporosis ```
61
What are the complications of radical prostatectomy
Erectile dysfunction | Urinary incontinence
62
What is a normal post voidal volume in patients aged <65
<50ml
63
Describe epididymo-orchitis
Inflammation of the epididymis and testicle
64
Describe the anatomy of the testicle
At the back of each testicle is the epididymis - sperm are released from the testicle into the head of the epididymis and travel through the head, body and tail. The sperm mature and are stored in the epididymis. This drains into the vas deferens
65
List the causes of epididymo-orchitis
E.coli Chlamydia trachomatis Neisseria gonorrhoea Mumps
66
Describe the symptoms of mumps
Parotid gland swelling Orchitis - only affecting testicle Pancreatitis
67
Describe the presentation of epididymo-orchitis
``` Testicular pain Dragging or heavy sensation Swelling of testicle and epididymis Tenderness on palpation Urethral discharge Systemic symptoms - fever and potentially sepsis ```
68
What is the key differential diagnosis of epididymo-orchitis
Testicular torsion
69
Describe how epididymo-orchitis is diagnosed
Urine microscopy, culture and sensitivity Chlamydia and gonorrhoea NAAT testing on first pass urine Charcoal swab of purulent discharge for gonorrhoea culture and sensitivities Saliva swab - PCR - mumps Serum antibodies Ultrasound - torsion and tumour
70
Describe the management of epididymo-orchitis
Acutely unwell or septic patients - IV antibiotics Patients with high risk of STI - urgent GUM referral Local guidelines guide choice of antibiotic - low risk of STIS a typical choice is ofloxacin for 14 days or ciprofloxacin, doxycycline or co-amoxiclav Additional measures - analgesia, supportive underwear, reduce physical activity, abstain from intercourse
71
Describe the use of quinolone antibiotics
Ofloxacin and ciprofloxacin - powerful broad spectrum antibiotics used for UTIs, pyelonephritis, epidymo-orchitis and prostatitis Give excellent gram negative cover
72
List two side effects of quinolone antibiotics
Tendon damage/rupture (Achilles) | Lower the seizure threshold
73
What are the complications of epididymo-orchitis
``` Chronic pain Chronic epididymitis Testicular atrophy Sub-fertility or infertility Scrotal abscess ```
74
List some features which make an STI cause of epididymo-orchitis more likely than E.coli
<35yo Increased number of sexual partners Discharge from urethra
75
Describe testicular torsion
Twisting of the spermatic cord with rotation of the testicle Urological emergency Can lead to ischaemia and necrosis of the testicle - sub/infertility May be history of recurrent symptoms where there is intermittent testicular torsion Usually triggered by activity
76
Describe the examination findings of testicular torsion
``` Firm swollen testicle Elevated (retracted) testicle Absent cremasteric reflex Abnormal testicular lie Rotation so the epididymis is not in normal posterior position ```
77
Describe the presentation of testicular torsion
Unilateral testicular pain Acute rapid onset Abdominal pain and vomiting
78
What is a Bell-clapper deformity
A cause of testicular torsion Fixation between the tunica vaginalis and testicle is absent so the testicle hangs in a horizontal position instead of vertical and more likely to rotate within the tunica vaginalis twisting on the spermatic cord and cutting off the blood supply
79
Describe the management of testicular torsion
``` Urological emergency NBM Analgesia Urgent senior urology assessment Surgical exploration of scrotum Orchidopexy - fixing them in place Orchidectomy - removal of the testicle if necrotic ```
80
What can be used to diagnose testicular torsion
Scrotal ultrasound - whirlpool sign - spiral appearance to the spermatic cord and blood vessels
81
What is a hydrocele?
Collection of fluid in the tunica vaginalisis that surrounds the testes
82
How do hydroceles present
``` Painless swelling of the scrotum Palpable testicle within Soft, fluctuant and may be large Irreducible and no bowel sounds Trans illuminated ```
83
What causes hydroceles
Idiopathic | Can be secondary to testicular cancer, testicular torsion, epididymo-orchitis and trauma
84
Describe the management of hydroceles
Exlcude serious causes Idiopathic managed conservatively Surgery, aspiration or sclerotherapy if large or symptomatic
85
Describe a varicocele
When the veins in the pampiniform plexus (venous plexus found in the spermatic cord and drains the testes into the testicular vein, has a role in temperature control of blood entering the testes ) become swollen as a result of increased resistance in the testicular vein and incompetent valves in the testicular vein allowing blood to flow back into pampiniform plexus. Common in 15% of men Can cause impaired fertility - due to disrupting the temperature in the affected testicle May result in testicular atrophy, reducing the size and function of the testicle
86
Where does the right testicular vein drain
IVC
87
Where does the left testicular vein drain
Left renal vein
88
Which side are most varicoles
Left sided due to increased resistance in the left testicular vein
89
What might a left sided varicole indicate
Renal cell carcinoma
90
Describe the presentation of varicoceles
Throbbing/dull pain or discomfort worse on standing Dragging sensation Subfertility or infertitlity
91
Describe examination findings of a varicocele
Bag of worms - scrotal mass More prominent when standing and disappears when lying down Asymmetry in testicular size if affected the growth of the testicle
92
What do varicoceles which do not disappear when sitting down raise suspicion of
Retroperitoneal tumour
93
Describe the investigations of varicoceles
US with doppler imaging Semen analysis if fertility concern hormone function - FSH and testosterone if concern about functioning
94
Describe the management of varicoceles
Uncomplicated - conservative Pain, testicular atrophy or infertility - surgery or endovascular embolisation
95
Describe epididymal cysts
Cysts occuring at the head of the epididymis Contains sperm - spermatocele Common in adults Most asymptomatic Round, soft lump at top of testicle associated with the epididymis and separate from the testicle. May be able to trans illuminate large cysts appearing separate from the testicle. Usually harmless and not associated with cancer or infertility occasionally pain or discomfort and removal considered or torsion
96
Describe testicular cancer
Arises from germ cells that produce gametes Common in younger men 15-35yo Two types - seminomas and non seminomas (teratomas)
97
List some risk factors for testicular cancer
Undescended testes Male infertility FH Increased height
98
Describe the presentation of testicular cancer
``` Painless lump Non tender Arising from testicle Hard Irregular Not fluctuant No transillumination Gynaecomastia - leydig cell tumour (rare) ```
99
What investigations should you do for testicular cancer
Scrotal ultrasound Tumour markers - AFP, beta hCG, lactate dehydrogenase Staging CT
100
Describe the staging system for testicular cancer
``` Royal marsden staging system 1 - isolated to testicle 2 - spread to the retroperitoneal lymph nodes 3 - spread to nodes above the diaphrgm 4 - metastasis ```
101
Where does testicular cancer metastasise to
Lymphatics Lungs Liver Brain
102
Describe the management of testicular cancer
``` MDT Surgery - radical orchidectomy Chemotherapy Radiotherapy Sperm banking ```
103
Which type of testicular cancer has the better prognosis
Seminomas > teratomas
104
Describe lower urinary tract infections
Infection of the bladder
105
Describe the presentation of lower urinary tract infections
``` Dysuria Suprapubic pain or discomfort Frequency Urgency Incontinence Haematuria Cloudy or foul smelling urine Confusion ```
106
What might urine dipstick show in lower urinary tract infection
Nitrites - gram negative bacteria break down nitrates to form nitrites - suggest bacteria in urine Leukocytes - white blood cells, leukocyte esterase is tested on urine dipstick which is a product of leukocytes Red blood cells - indicates blood - microscopic haematuria is where blood is visible in the urine - seen in bladder cancer or nephritis
107
When should a midstream urine sample (MSU) be sent for microscopy, culture and sensitivities
Pregnant patients Patients with recurrent UTIs Atypical symptoms When symptoms do not improve with antibiotics
108
List the causes of lower urinary tract infections
``` E.coli - gram negative anaerobic rod shaped bacteria Klebsiella pneumoniae Enterococcus Pseudomonas aeruginosa Staphylococcus saprophyticus Candida albicans ```
109
Describe the antibiotic therapy for lower urinary tract infection
Trimethoprim (avoid in 1st trimester pregnancy) Nitrofurantoin (avoid in 3rd trimester pregnancy and if eGFR is <45) Amoxicillin Cefalexin Pivmecillinam 3 days of antibiotics - lower UTI in women 5-10days of antibiotics for immunosuppressed women, abnormal anatomy or impaired kidney function 7 days antibiotics for men, pregnant women or catheter related UTIs
110
Describe pyelonephritis
Inflammation of the kidney resulting from bacterial infection Inflammation affects the renal pelvis and parenchyma
111
List some risk factors for pyelonephritis
Female sex Structural urological abnormalities Vesico-ureteric reflux Diaabetes
112
Which bacteria cause pyelonephritis
``` E.coli Klebsiella pneumoniae Enterococcus Pseudomonas aeruginosa Staphylococcus saprophyticus Candida albicans ```
113
Describe the presentation of pyelonephritis
``` Fever Loin or back pain Nausea or vomiting Systemic illness Loss of appetite Haematuria Renal angle tenderness on examination ```
114
Describe the investigations for pyelonephritis
Urine dipstick - nitrites, leukocytes and blood Midstream urine for microscopy, culture and sensitivity Bloods - raised WCC and raised inflammatory markers Imaging - ultrasound and CT scan
115
Describe the management of pyelonephritis
Refer to hospital if features of sepsis 7-10days of antibiotics - co-amoxiclav, trimethoprim, ciprofloxacin, cefalexin - refer to guidelines Sepsis 6 if sepsis
116
Describe chronic pyelonephritis
Recurrent episodes of infection in the kidneys | Lead to scarring of the renal parenchyma - CKD - can progress to end stage renal failure
117
Describe the scan done in chronic/recurrent pyelonephritis
DMSA scan - inject radiolabelled DMSA which builds up in healthy kidney tissue When imaged using gamma cameras it indicates scarring or damage in areas that do not take up the DMSA Used in recurrent pyelonephritis to assess for renal damage
118
Describe interstitial cystitis
Chronic condition causing inflammation of the bladder, resulting in lower urinary tract symptoms and suprapubic pain No explanation fort cause - dysfunction of blood vessels, nerves, immune system and epithelium More common in women than men - impact on QOL and mental health
119
Describe the presentation of interstitial cystitis
>6 weeks Suprapubic pain - worse with full bladder and better when emptying bladder Frequency Urgency Symptoms worse during menstruation
120
What investigations are done for interstitial cystitis
Urinalysis Swabs Cystoscopy - Hunner lesions (red, inflamed patches of bladder mucosa associated with small blood vessels), granulations (haemorrhages on the bladder wall) Prostate examination
121
Describe the management of interstitial cystitis
Supportive - diet change, stop smoking, pelvic floor exercises, bladder retraining, CBT, transcutaneous electrical nerve stimulation Oral medications - analgesia, antihistamines, anticholinergic medications, mirabegron, cimetidine, pentosan polysulfate sodium, ciclosporin Intravesical medication - lidocaine, hyaluronic acid, chondroitin sulphate Hydrodistension - fill bladder with water to a high pressure, during cystoscopy - requires GA and gives a temporary improvement of symptoms Surgical procedures - cauterisation of Hunner lesions, Botulinum toxin, neuromodulation, augmentation, cystectomy
122
List some risk factors for bladder cancer
Smoking - TCC Age Aromatic amines - carcinogens - dyes and rubber Schistosomiasis - SCC
123
Name the two main types of bladder cancer
Transitional cell carcinoma (90) Squamous cell carcinoma (5%) Others - adenocarcinoma, sarcoma and small cell carcinoma
124
How does bladder cancer present
Painless haematuria
125
Who should be referred under 2ww pathway for bladder cancer
>45yo with unexplained visible haematuria either without a UTI or persisting after UTI treatment >60 with microscopic haematuria plus dysuria or raised WBCs on FBC
126
How is bladder cancer diagnosed
Cystoscopy - rigid or flexible under LA/GA
127
Describe the staging of bladder cancer
TNM staging system Non-muscle invasive bladder cancer (Tis/carcinoma in situ - cells affect urothelium and are flat, Ta - cancer affects the urothelium and projects into the bladder, T1 - cancer invading the connective tissue layer beyond the urothelium but not muscle layer) Muscle invasive bladder cancer - T2-4 and any lymph node or metastatic spread
128
Describe the treatment options for bladder cancer
Transurethral resection of the bladder tumour - non-muscle-invasive bladder cancer Intravesical chemotherapy Intravesical bacillus calmette-guerin (BCG) - form of immunotherapy - BCG vaccine given into the bladder to stimulate immune system to attack the tumour Radical cystectomy - urostomy with ileal conduit (most common), continent urinary diversion, neobladder reconstruction, ureterosigmoidostomy, chemo and radiotherapy Chemo and radiotherapy
129
Describe an ileal conduit
A section of ileum is removed and end-to-end anastomosis is created so the bowel is continuous. The ends of the ureters are anastomosed to the separate section of the ileum and the other end of this section of ileum forms a stoma out to the skin draining the urine into a urostomy bag Urostomy bags need to fit tightly around the urostomy to avoid skin contact with urine as this is irritating and may cause skin damage
130
What are two complications of kidney stones
Obstruction | Infection
131
List the different types of kidney stone
Calcium based stones (80%) - calcium oxalate and calcium phosphate - Having raised serum calcium and low urine output Uric acid - not visible on X-ray Struvite - associated with infection as produced by bacteria Cystine - associated with cystinuria - autosomal recessive
132
Describe a staghorn calculus
Stone forms the shape of a renal pelvis Body sits in the renal pelvis with horns extending into the renal calyces Plain Xray Struvite - occur in recurrent upper UTIs Bacteria hydrolyse the urea in urine to ammonia creating solid struvite
133
Describe the presentation of kidney stones
Renal colic - unilateral loin to groin pain Colicky as the stone moves and settles Patients often restless due to pain Haematuria Nausea and vomiting Reduced urine output Symptoms of sepsis if infection is present
134
Describe the investigations for kidney stones
Urine dipstick - haematuria Bloods- infection and kidney function and raised serum calcium Abdominal X-ray - show calcium stones and struvite stones, do not show uric acid stones Non-contrast computer tomography (CTKUB) - <24hrs of presentation - initial investigation to diagnose stones Ultrasound KUB is less preferred alternative - negative result does not exclude the stones - helpful in children and pregnant women Stones should be analysed to determine type and reduce the risk of recurrence
135
Describe the initial management of kidney stones
NSAIDs - IM diclofenac, IV paracetamol if NSAIDs CI Antiemetics - metoclopramide, Cyclizine, prochlorperazine Antibiotics - required if infection present Watchful waiting - if <5mm may pass themselves within several weeks. Stones >10mm may require Tamsulosin (alpha blocker) or surgical interventions (extracorporeal shockwave lithotripsy, ureteroscopy and laser lithotripsy, percutaneous nephrolithotomy and open surgery)
136
How are recurrent kidney stones reduced
Drink plenty of fluid (3L) Add fresh lemon juice to water (reduce formation of calcium stones) Avoid carbonated drinks Reduce dietary salt and protein Maintain low calcium diet Calcium stones- reduce intake of oxalate rich foods and for uric stones - reduce purine rich food
137
List two medications used to reduce recurrence of kidney stones
Potassium citrate - reduce calcium oxalate stones Thiazide diuretics reduce calcium oxalate stones and raised urinary calcium
138
What type of cancer is a renal cell carcinoma
Adenocarcinoma arising from the renal tubules
139
How does renal cell carcinoma present
``` Asymptomatic Haematuria Loin pain Non-specific symptoms of cancer -weight loss, fatigue, anorexia, night sweats Palpable renal mass on examination ```
140
List the different types of renal cell carcinoma
Clear cell (80%) Papillary (5%) Chromophobe (5%)
141
List some risk factors for renal cell carcinoma
``` Smoking Obesity HTN End stage renal failure Von Hippel Lindau disease Tuberous sclerosis ```
142
Describe the spread of renal cell carcinoma
Around tissues of kiney within gerotas fascia Spreads to renal vein then to IVC Cannonball metastases in the lungs is a classic feature of metastatic renal cell carcinoma
143
List some paraneoplastic features of RCC
Polycythaemia - increased EPO Hypercalcaemia HTN Stauffers syndrome - abnormal liver function tests without liver mets
144
Describe the staging of renal cell carcinoma
``` CT TAP TNM staging Number staging for renal cell carcinoma 1- <7cm 2- > 7cm 3 - local spread but not beyond gerotas fascia Stage 4 - spread beyond fascia ```
145
Describe the management of renal cell carcinoma
``` MDT Surgery - partial/radical nephrectomy Arterial embolisation Percutaneous cryotherapy Radiofrequency ablation Chemotherapy and radiotherapy ```
146
Describe renal transplant
Where a kidney transplanted into a patient with end stage failure
147
How are renal transplant patients donor matched?
HLA matching - HLA A,B,C on chromosome 6 - don't have to match fully but the closer the better
148
Describe the process of transplanting a kidney
Patients own kidney left in place Donor kidney blood vessels anastomosed with pelvic vessels - external iliac vessels Ureter of donor kidney anastomosed directly with bladder Donor kidney placed anteriorly in abdomen - palpated in iliac fossa
149
What is the name of the incision used in renal transplant
Hockey stick
150
What is required following kidney transplant
Life long immunosuppression - Tacrolimus - Mycophenolate - Prednisolone Other possible immunosuppressants - cyclosporine, sirolimus, azathioprine
151
What is the main side effect of tacrolimus
Tremor
152
What may immunosuppressants cause
Seborrheic warts | Skin cancer
153
What is the main side effect of cyclosporine
Gum hypertrophy
154
What are the complications of the transplant
Rejection - hyper acute, acute and chronic Transplant failure Electrolyte imbalance
155
List some complications relating to immunosuppressants
``` IHD T2DM Non-Hodgkin's lymphoma Skin cancer Infections - CMV, TB and pneumocystis jivoreci pneumonia ```
156
What is the most useful investigation to help diagnose overactive bladder
Bladder diary/frequency volume
157
What is the most appropriate medication for treating urinary urgency
Anticholinergics (inhibition of muscarinic receptors elsewhere)- oxybutynin Beta 3 agonists - mirabegron
158
List some side effects of anticholinergics
Dry mouth Reduced lacrimation Constipation Memory problems in older people
159
What is the best surgical approach for radical orchidectomy and why
Inguinal as a scrotal approach may cause seeding and increase the risk of lymph node involvement

Finals (18 decks)

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