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Urology Flashcards

1
Q

What is the pathophysiology of Benign Prostate Hyperplasia?

A

There is hyperplasia of a different set of cells first- the GLANDULAR EPITHELIAL CELLS and the STROMAL CELLS (connective tissue).

This increases the activity of the 5-ALPHA REDUCTASE enzymes

This enzyme produces high amounts of DIHYDROTESTOSTERONE (DHT) and OESTROGEN

DHT is what acts on ANDROGEN RECEPTORS in the prostate and causes HYPERPLASIA

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2
Q

What zone of the prostate is affected in Benign Prostate Hyperplasia?

A

The Transition Zone

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3
Q

What are the 4 risk factors for Benign Prostate Hyperplasia?

A

Being Black, then being White, then being Asian

Diabetes

Obesity

Increasing Age

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4
Q

What are the 3 signs of Benign Prostate Hyperplasia?

A

Lower UTI Symptoms- hesitancy, terminal dribbling, weak stream, straining or incomplete emptying

Lower abdominal tenderness and palpable bladder- indicates Acute Urinary Retention- Patient requires urgent BLADDER SCAN and URGENT CATHETERISATION

Smooth, Enlarged and Non-tender Prostate in Digital Rectal Examination

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5
Q

What 6 investigations should be conducted if Benign Prostate Hyperplasia is suspected?

A

Pyuria (indicates infection)

PSA (Prostate-Specific Antigen)- correlates to size of prostate

U&Es- if the obstruction is severe then it could cause renal failure

Transrectal Ultrasound- to estimate the size of the Prostate

Renal Tract Ultrasound- if acute urinary retention is suspected then this is done to check for Hydronephrosis

A flow rate <20

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6
Q

How do you manage Benign Prostate Hyperplasia?

(3 steps if symptoms are bothersome)

Surgery is considered in severe cases (covered in a separate card)

A

If the symptoms are bothersome- then give ALPHA BLOCKERS like TAMSULOSIN to relax the smooth muscles and 5-ALPHA REDUCTASE INHIBITORS like FINASTERIDE to inhibit the formation of DHT

Then for Second-line, just combine them both

Also give a PHOSPHODIESTERASE-5 INHIBITOR like SILDENAFIL

If the symptoms are not bothersome- treat the constipation, reduce caffeine and fluid intake

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7
Q

What are the 4 side effects of Tamsulosin and 3 side effects of Finasteride, which are given as treatment for Benign Prostate Hyperplasia?

A

Tamsulosin-

  • Postural Hypertension
  • Dizziness
  • Dry mouth
  • Depression

Finasteride-

  • Reduced Libido
  • Erectile Dysfunction and Reduced Ejaculate Volume
  • Gynaecomastia
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8
Q

What are the indications for surgery in Benign Prostate Hyperplasia?

A

RUSHES

  • Recurrent or Refractory Urinary Retention
  • Recurrent UTI
  • Bladder Stone
  • Haematuria (not stopped by medication)
  • Elevated Creatinine due to the bladder outflow obstruction
  • Symptoms deteriorate despite medical therapy
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9
Q

What are the 3 surgeries considered for Benign Prostate Hyperplasia and the requirements for each one?

A

TUIP- if Prostate<30
TURP- if Prostate 30-80
Open Prostatectomy- if Prostate >80

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10
Q

What are the two main types of Bladder Cancer (one of them is 90% of the cases)

A

Transitional Cell Carcinoma (90% of cases)

Squamous Cell Carcinoma

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11
Q

What are the two main types of Transitional Cell Carcinoma (main type of Bladder Cancer)

What are 2 things about each type

A

Papillary- MAJORITY of the TCC cases

  • Superficial cancer with FINGER-LIKE PROJECTIONS
  • Often Non-invasive with a Better Prognosis

Flat-

  • They lie flat against the bladder
  • More prone to Invasion with a Poor Prognosis
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12
Q

What is Squamous Cell Carcinoma (the rare type of Bladder Cancer) associated with?

A

Chronic Cystitis- secondary to Schistosoma Haematobium

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13
Q

What are the 4 risk factors for Bladder Cancer?

A

Male

Smoking

Occupational Exposure (3)

  • Aromatic Amines (rubber, dye and textile industries)
  • Polycyclic Aromatic Hydrocarbons (aluminium, coal and roofing industries)
  • Painters and Hairdressers

Risk factors for Squamous Cell Carcinoma
- Schistosoma Haematobium

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14
Q

What are the 6 signs of Bladder Cancer?

A

PAINLESS Haematuria

Dysuria

Frequency

Weight loss

Anaemia- Pallor if Chronic Bleeding is Present

Palpable Suprapubic Mass

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15
Q

What are the two main referral pathways for Bladder Cancer and the age ranges for each Patwhay?

A

45 Years Old and Above-

  • Unexplained Haematuria Without UTI
  • Haematuria that doesn’t go away after treatment of UTI

60 Years Old and Above-
- Unexplained Haematuria and either Dysuria OR a Raised WCC Count

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16
Q

What are the 8 investigations to be ordered if Bladder Cancer is suspected?

A

Flexible Cystoscopy is conducted to confirm the presence of the Bladder Cancer

CT Urogram- to image the Urinary Tract and visualise the Renal Parenchyma

PET-CT- if the CT is unclear

Haematuria

Assess Bone Profile- Hypercalcaemia and Raised ALP (seen in Bone Metastasis)

Bone Scan- if Bone Metastasis is suspected

LFTs and Coagulation- usually Deranged in Liver Metastasis

CT Abdomen and Pelvis- assesses for distant metastasis for High-Risk Patients or Suspected Muscle-Invasive Disease.
- This is not needed if the Patient is Low-Risk or has no risk of Muscle-Invasion

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17
Q

What are the 3 management pathways for Bladder Cancer (2 steps in each pathway)

A

If it is superficial and NOT Muscle-invasive-

  • Trans-urethral Resection of Bladder Tumor- which is performed through Rigid Cystoscopy under general anaesthetic
  • Give a post-operative dose of Mitomycin C

If it is Muscle-Invasive-

  • Radical Cystectomy- with Neoadjuvant and Adjuvant Chemotherapy
  • Radical Radiotherapy- with Neoadjuvant Chemotherapy

If it is Locally-advanced or Metastatic

  • Chemotherapy- Cisplatin-based chemotherapy
  • Palliative Treatment- Radiotherapy for bladder symptoms
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18
Q

Which microorganisms cause Epididymo-Orchitis through STI (3) and non-STI (2)?

A

STI

  • Chlamydia trachomatis
  • Neisseria gonorrhoea
  • Mycoplasma genitalium

Non-STI

  • E. Coli
  • Proteus Sp.
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19
Q

What ae the 3 risk factors for Epididymo-Orchitis?

A

STI-related- Multiple Partners, Young, Unprotected Sex

Enteric-related- Elderly, Bladder Outflow Obstruction, Instrumentation of Urinary Tract

Tuberculosis (TB) can cause Epididymo-Orchitis

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20
Q

What are the 5 signs of Epididymo-Orchitis?

A

Lower UTI Symptoms- Like Dysuria, Hesitancy, Nocturia

Unilateral, Tender, Swollen Testicle

Present Prehn’s sign- relief when lifting the testicle (absent in Testicular Torsion)

Present Cremasteric reflex (absent in Testicular Torsion)

Pyrexia (but may not be present)

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21
Q

What 3 investigations should be ordered if Epididymo-Orchitis is suspected?

A

Urinalysis (remember Neisseria Gonorrhoea is Gram-Negative)

Nucleic Acid Amplification Test- detect the DNA/ RNA of the causative organism

Swab of urethral secretions- but this is less sensitive that NAAT

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22
Q

What is the first-line management for STI and enteric causes of Epididymo-Orchitis?

A

STI-
- Ceftriaxone and Doxycycline

Enteric-
- Fluoroquinolones such as Ofloxacin or Ciprofloxacin

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23
Q

What is the most common type of Prostate Cancer and which zone of the Prostate do they usually arise from?

A

Adenocarcinomas- they arise from the Peripheral Zone of the Prostate

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24
Q

What 2 genes are associated with Prostate Cancer?

A

BRCA1 and BRCA2

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25
What are the three risk factors for Prostate Cancer?
Increasing Age Afro-Caribbean Ethnicity Cadmium Exposure (3) - Cigarettes - Battery - Working in the welding industry
26
What are the 7 signs of Prostate Cancer?
Common Lower UTI Symptoms (4) - Frequency - Hesitancy - Terminal Dribbling - Nocturia Less Common Lower UTI Symptoms (2) - Haematuria - Dysuria Bone Pain (Lumbar Back Pain suggests a Metastatic Disease) Asymmetrical Hard Nodular Prostate with a Loss of the Median Sulcus Palpable Lymphadenopathy indicates Metastatic Disease Urinary Retention (Lower Abdominal Pain and Tenderness, Inability to Urinate and Palpable Bladder) Weight Loss
27
What 7 investigations should be ordered if Prostate Cancer is suspected?
Multiparametric MRI (is First Line)- conduct if >2 on the Likert Scale Gleason Score is used to assess severity (8-10 is severe with low differentiation) PSA (>2.5) U&Es to assess for renal failure Bone Profile- Hypercalcaemia and Raised ALP suggests Bone Metastasis Bone Scan- if bone metastasis is suspected Liver Profile to assess for Liver Metastasis
28
What are the treatment options for Low (3) and High (4) Risk Non-Metastatic Prostate Cancer? Low-risk= PSA is 10 or lower, Gleason Score is 3+3, Cancer Stage is T1 or T2
Low-Intermediate Risk Non-Metastatic Prostate Cancer- - Active Surveillance or Observation - Radical Prostatectomy - Radical Radiotherapy or Brachytherapy with or without AntiAndrogen Therapy High Risk Non-Metastatic Prostate Cancer- - Radical Prostatectomy - Radical Radiotherapy with AntiAndrogen Therapy - Radical Radiotherapy with Brachytherapy - Docetaxel Chemotherapy with AntiAndrogen Therapy
29
What are the two options for the management of Metastatic Prostate Cancer?
Docetaxel Chemotherapy with AntiAndrogen Therapy Bilateral Orchidectomy
30
What are the two types of AntiAndrogen Therapy offered in Prostate Cancer and which one should be offered before the other?
Anti-Androgens- - Flutamide LHRH Agonists- - Goserelin - Zoladex Anti-Androgens should be given before LHRH Agonist
31
What type of carcinoma is Renal Cell Carcinoma and where does this type originate from?
Adenocarcinoma- arises from the Epithelium of the Proximal Convoluted Tubule (HYPERNEPHROMA)
32
What is the most common histological variant of Renal Cell Carcinoma?
Clear Cell Carcinoma
33
What gene is associated with Renal Cell Carcinoma and what 4 conditions is this gene associated with?
The Von-Hippel-Lindau Gene It is associated with- - Renal Cell Carcinoma - Pheochromocytoma - Cerebellar Hemangioblastoma - Tuberous Sclerosis
34
What are the 4 endocrine associations of Renal Cell Carcinoma?
Erythropoeitin- Polycythaemia Parathyroid Hormone-related Peptide- Hypercalcaemia ACTH- Cushing's Renin
35
What are the 5 Histological Subtypes of Renal Cell Carcinoma? State a fact about each of them
Clear Cell- Most Common Papillary- Second Most Common Chromophobe- Large, Pale Cells and associated with an Excellent Prognosis Multiocular Cystic- Associated with an Excellent Prognosis Renal Medullary- VERY AGGRESSIVE, patients are often Metastatic at presentation
36
What are the 3 main risk factors for Renal Cell Carconoma?
Black Male Smoking
37
What are the 6 signs of Renal Cell Carcinoma?
Haematuria/ Flank Pain and Abdominal Pain (but only seen in 10% of patients) Flank Mass Asymptomatic in most cases- diagnosed incidentally Left-sided Varicocele Constitutional Symptoms (Weight loss, Fatigue, FEVER of unknown origin) Evidence of Metastatic Disease (Shortness of Breath, Chronic Liver Disease, Bone Pain)
38
What 11 Investigation should be ordered in Renal Cell Carcinoma?
CT Abdomen and Pelvis- for a definitive diagnosis Abdominal Ultrasound to help differentiate between benign and malignant lesions CT Chest- if initial imaging suggests a malignancy Assessment for Microscopic Haematuria and Proteinuria FBC- Anaemia of Chronic Disease or Polycythaemia U&Es- Check for Renal Dysfunction LFTs and Coagulation- derangement suggests Liver Metastasis Bone Profile- Elevated Calcium is a Poor Prognostic Marker and indicates Bone Metastasis Bone Scan- if there is evidence of bone metastasis (pain or hypercalcaemia) LDH- Elevated LDH is a poor prognostic marker Renal Biopsy- risk of tumour spreading to surrounding structures
39
What are the 3 options for the treatment of Non-Metastatic Renal Cell Carcinoma?
Partial Nephrectomy- standard for T1 Tumours (7cm or less) Radical Nephrectomy- standard for T2-T4 Tumours (more than 7cm) - Consider Local Lymph Node Dissection and Adrenalectomy if these structures are involved Minimally-invasive procedures such as Radiofrequency Ablation or Embolism are reserved for patients who are unfit for surgery
40
What are the 3 options for the treatment of Metastatic Renal Cell Carcinoma?
Molecular Therapy- Sunitinib and Pazopanib are first line agents (considered before Interferon Alpha) Radiotherapy Cytoreductive Surgery
41
What are the 5 complications of Renal Cell Carcinoma?
Metastasis Polycythaemia (EPO) Hypercalcaemia (PTHrP) (Parathyroid hormone-related peptide) Cushing's Syndrome Stauffer Syndrome - Paraneoplastic Nephrogenic HEPATOMEGALY - RCC can result in HEPATOMEGALY, CHOLESTASIS and CHOLESTATIC JAUNDICE- secondary to an increased IL6
42
What are the majority of Renal Stones composed of?
Calcium Oxalate
43
What are the 8 risk factors for Renal Stones?
Male Eating Stone-Forming Foods Systemic Diseases- such as Crohn's Disease Metabolic Conditions (3)- Hypercalcaemia, Hyperparathyroidism, Hypercalciuria Loop Diuretics and Acetazolamide cause Calcium Stones Protease Inhibitors (HIV medication) causes Radiolucent Stones Exposure to certain things- Cadmium and Beryllium Gout and Ileostomies- causes Uric Acid Stones
44
What are the 5 signs of Renal Stones?
Acute, Severe Flank Pain (writhing around) - Loin to Groin Hypotension and Tachycardia indicates Urosepsis/ a Septic Stone Fever- suggests Septic Stone Nausea and Vomiting Differentiate this from a Ruptured Abdominal Aortic Aneurysm- especially in elderly males with a new onset flank pain and no history of stones
45
What 4 investigations should be ordered if Renal Stones are suspected?
Non-Contrast CT Kidney, Ureter, Bladder is Gold Standard Urinalysis- Microscopic Haematuria with Pyuria if Pyelonephritis is present U&Es- raised Creatinine- check for AKI caused by Severe Obstruction Bone Profile and Urate- Hypercalcaemia suggests Hyperparathyroidism
46
What is the Acute management for Renal Stones? (2)
IV Fluids and Anti-emetics Analgesia (NSAIDs) - PR Diclofenac - or IV Paracetamol if NSAIDs are contraindicated
47
What is the Conservative management for Renal Stones? (2)
Watchful Waiting as stones<5mm should pass spontaneously Ureteric stones 5-20mm- give them Tamsulosin
48
What is the Surgical management for Renal Stones? (5)
Ureteroscopy Extracorpeal Shock Wave Lithrotripsy- Contraindicated in Pregnancy so use Ureteroscopy instead Percutaneous Nephrolithotomy- access via Surgical Incision in the back Ureteral Stenting- Insertion of a plastic tube to assist drainage Percutaneous Nephrostomy- Insertion of rubber tube into kidney to drain urine
49
What are the 5 types of Renal Stones?
Calcium Oxalate (Majority) Struvite Calcium Phosphate Uric Acid Cysteine
50
What are 6 facts about Struvite Renal Stones?
UTI with Urease Producing Organisms (like Proteus mirabilis) can cause this Consists of Magnesium, Phosphate and Ammonium Coffin Lid-shaped stones They can cause Staghorn Calculi Mildly radiopaque Caused by High Levels of Ammonium and Bicarbonate
51
What 2 conditions cause Calcium Phosphate Stones and are they radiopaque/ lucent?
Hypercalcaemia (like from Hyperparathyroidism Hypercitraturia They are very radiopaque- like bone
52
What 4 conditions can cause Uric Acid Stones? And are they radiopaque/lucent?
Gout Hyperuricosuria Dehydration Hot Climates They are radiolucent
53
What are 3 facts about Cysteine Renal Stones?
Caused by Cysteinuria Hexagonal Shaped They are SEMI-OPAQUE and have a Ground-Glass Appearance
54
What 2 type of tumours can be seen in Testicular Cancers?
Germ Cell Tumours- they arise from Haploid Germ Cells which take part in Spermatogenesis Non-germ Cell Tumours- they arise from Diploid Sex-Cord Stroma Cells
55
What 2 types of tumours can Germ Cell Tumours (like Testicular Cancers) be divided into?
Seminomas and Non-Seminomas
56
What are the 5 types of Germ Cell Tumours (like Testicular Cancer) and state 1 fact about each?
Seminomas- these are the most common Embryonal Carcinomas- these are aggressive and metastasise early Teratomas- common in children- these are composed of tissue from a different germinal layer- like TEETH Yolk-sac Tumours- common in children Choriocarcinoma- rare but aggressive
57
What are the 2 types of Non-germ Cell Tumours (like Testicular Cancer) and state 1 fact about each?
Leydig Cell Tumour- Androgen-secreting- causes precocious puberty Sertoli Cell Tumour- usually Clinically Silent
58
What are the 4 main risk factors for Testicular Cancer?
Cryptorchidism- Undescended Testes Young Male>35 years old- Seminomas, <35 years old- Non-Seminomas Caucasian Intersex Conditions (Klinefelter's)
59
What are the 5 signs of Testicular Cancer?
Painless testicular lump (firm and non-tender, does not transluminate) Conditions related to Beta-HCG (2)- Hyperthyroidism (as Beta-HCG mimics TSH) and Gynaecomastia Bone pain- indicates skeletal metastasis Breathlessness indicates lung metastasis Superior Lymphadenopathy
60
What are the 3 investigations to be ordered in Testicular Cancer+ name the 5 tumour markers?
First-line= ULTRASOUND Testicular Doppler Do NOT DO- Fine Needle Aspiration- Do NOT 5 Tumour Markers- - Seminoma- Beta hCG - Embryonal Carcinoma- AFP - Teratoma- AFP - Yolk sac Tumour- AFP - Choriocarcinoma- Beta hCG
61
What are the 3 management steps for Non-Metastatic Seminomas and Non-seminomas (Testicular Cancer)?
Seminoma- - Radical Orchiectomy - Then Post-Orchiectomy active surveillance if low-risk - Or Post Radiotherapy or Chemotherapy with Carboplatin Non-Seminoma- - Radical Orchiectomy - Then Post-Orchiectomy active surveillance if low-risk - Post-Orchiectomy Combination Therapy
62
What is the 3 step management plan for Metastatic Testicular Cancer?
- Radical Orchiectomy - Then for Seminoma- Adjuvant combination chemotherapy or radiotherapy - For Non-Seminoma- Combination Chemotherapy
63
What is the pathophysiology of the Bell Clapper Abnormality, which is a risk factor for Testicular Torsion?
Bell Clapper Abnormality describes a HIGH RIDING TESTICLE with a HORIZONTAL LIE A developing testicle typically descends down the inguinal canal and is covered in PERITONEUM as it does so This layer of peritoneum is known as the TUNICA VAGINALIS- which goes on to attach onto the scrotum The failure of the TUNICA VAGINALIS to properly attach onto the scrotum results in the Bell Clapper Abnormality
64
What is the Hydatid of Morgagni Torsion?
It is a torsion of the testicular appendage and mimics testicular torsion The Hydratid of Morgagni is an embryonic remnant of the MULLERIAN DUCT and is present on the upper pole Torsion of this can cause INTENSE PAIN and this characteristically causes a BLUE-DOT SIGN and is managed conservatively- be aware of this when looking for Testicular Torsion
65
What are the 3 risk factors for Testicular Torsion?
Cryptorchidism (Undescended Testicles) Bell Clapper Abnormality Trauma
66
What are the 6 signs of Testicular Torsion?
Sudden, unilateral, severe testicular pain A swollen, high-riding, tender testicle where the skin may be erythematous and red Nausea and Vomiting (not usually seen in Epididymo-Orchitis) Lower Abdominal pain Prehn's sign is negative- no relief upon lifting the testicle Absent Cremasteric Reflex- swiping the inner and superior part of the thigh does not pull the testicle up
67
What 3 investigations should be conducted if Testicular Torsion is suspected?
DO NOT DO THESE IF PHYSICAL EXAMINATION PROVES IT IS TORSION AS THIS IS AN EMERGENCY Surgical exploration IMMEDIATELY Urinalysis- make sure there is no leukocytes/ nitrites- urinalysis should be NORMAL Testicular ultrasound- whirlpool sign suggests torsion
68
What is the management of a Viable and Non-Viable testicle in Testicular Torsion?
Viable Testicle- - Bilateral Orchipexy- the contralateral testicle also needs to be fixed to avoid contralateral testicular torsion Non-Viable Testicle- - Ipsilateral Orchiectomy and Contralateral Orchipexy - The removal of the affected testicle and fixing the contralateral testicle to prevent contralateral testicular torsion
69
What usually causes Lower UTI? What 2 other ways can bacteria enter the bladder?
Bacteria from the Gastrointestinal Tract ascend from the urethra into the bladder Bacteria can also enter from the blood stream (especially if the patient is immunosuppressed) and directly through the insertion of a urinary catheter or through surgery
70
Which 4 organisms typically cause a Lower UTI?
E.Coli (most common) Proteus Mirabilis (associated with renal tract abnormalities like Calculi (Staghorn Calculi- producing Struvite renal stones) Klebsiella Candida- they are a rare cause and are typically associated with indwelling catheters, immunosuppression and contamination from the genital tract
71
What are the risk factors for a Lower UTI in Pre-menopausal women (3) and Post-menopausal women (4)?
Pre-menopausal - Intercourse - Mother with a history of UTI - History of UTI in childhood Post-menopausal - Atrophic vaginitis - Cystocele - UTI before menopause - Urinary incontinence
72
What are the 8 signs of a Lower UTI?
Non-specific generalised clinical features- Delirium, Lethargy and Reduced Appetite Delirium or Confusion Dysuria Frequency Urgency Changes in the urine appearance (Cloudy or Pungent Odour/ Haematuria) Suprapubic Discomfort Nocturia
73
What 3 symptoms would make a diagnosis of Pyelonephritis (Upper UTI) likely?
Fever Loin Pain Rigors
74
What 5 symptoms would make a diagnosis of Sepsis likely?
Loin pain Rigors Nausea Vomiting Altered Mental State
75
What 4 investigations should be considered if a Lower UTI is suspected?
Urine Dipstick- Positive Nitrites or Leukocytes and positive RBCs, although Negative can also mean UTI Urine Microscopy, Culture and Sensitivity- Request this in ALL women with Positive Leukocytes. Bacteria, WBCs and RBCs are expected If a Tumour, Bladder Stone or Diverticulum is suspected- a Cystoscopy must be considered If a Kidney Stone, Hydronephrosis or Renal Abscess is suspected- a Renal Tract Ultrasound must be considered
76
What is the First (2) and Second line (3) options for the management of Lower UTI in Non-Pregnant Women?
First line- - Nitrofurantoin (if eGFR is 45 or higher) - Trimethoprim Second line- - Nitrofurantoin (if not used as first line and if eGFR is 45 or higher) - Pivmecillinam - Fosfomycin single-dose sachet
77
What is the First (1) and Second line (2) options for the management of Lower UTI in Pregnant Women and Men?
First line- - Nitrofurantoin (if eGFR is 45 or higher) Second line- - Amoxicillin - Cefalexin
78
What are the 4 complications of a Lower UTI?
An ascending infection - Pyelonephritis - Renal and Peri-renal Abscess - Impaired Renal Function or Renal Failure - Urosepsis

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