Urology Flashcards
whats obstructive uropathy
blockage–> build up of urine and back pressure into kidneys- impairs renal function
internal urethral spincheter
external urethral sphincter
whats their innervcation
internal= ans- smooth muscle
external- voluntary- skeletal muscle
whats vesicoureteral reflux
urine refluxing from bladder into ureters
presenrtation of upper urinary tract obstruction
loin to groin pain/ flank
no/decreased urinary output
non specific systemic symptoms = vomiting
impaired renal function- raised creatitnine
tenderness in renal angle
presentaiton lower urinary tract obstruction
investigations for urinary obstruction diff / inability pass urine - poor flow, diff initiating, terminal dribbling
urinary retention- increased full bladder
impaired renal fucntion - raised creatitine
tenderness in renal angle
investigations of obstructive uropathy
us of bladder,kidneys, ureters
casues upper urinary tract obstruction
kindey stones
bladder cancer obsturcting ureteral opening
tumours pressing on ureters
ureteral strictures
retroperitoneal fibrosis
ureterocele = ballooning of distal portion of ureter- usulaly congential
casues lower urinary tract obstruction
benign prostatic hyperplasia
prostate cancer
bladder cancer blocking urethral opening
urethral strcitures
neurogenic bladder
whats neruogenic bladder and causes and result in
abnormal functioning of nerves innervating bladder and urethra
will result in over/under activity of detrusor muslce and spihincter urethra
casues of this are:
MS, diabtetes, stroke, parkinsons, spia bifida, spinal cord/brain injury
results in:
obstructive uropathy, urge incontinence, increase in bladder pressure
magangement of obstructive uropathy
need remove/ bypass obstruction
can do nephrostomy for upper tract
suprapubic/ urethral catheter for lower obstruction
complciations of obstructive uropathy
pain
aki
ckd
hydronepthrosis
urinary retnetion and bladder distenntion
overflow incontinenc eof urine
whats hydronephrosis and what can casue it and how treat
swlling of renal pelivs and calcyes
due to obstruction which casues bakc pressure
ca be due to idiopathic hydronephrosis = narrowing at pelviureteric junction = treat with pyeloplasty to correct narrowing
treatment other casues : treat cause and may need percuatneous nephrostomy/ anterograder uteric stent
presentation hydronephrosis
vague renal angle pain
mass in kidney area
may be seen on US/CT scan / iv urogram (xray with contrast)
indications for urinary catheter
urinary retnetion due to lower urinary tract obstruction
neurogenic bladde- eg. intermittent use in ms
surgery- before/after
outout monitoring
bladder irrigation
deleiver medication- chemo drugs
patient with enlarge proastate has acute urinary retnetion. insert a catheter. what meds start and the se
tamsulosin - alpha blocker
then twoc
se tamsulosin:
postrual hypotention –> dizzy on stnading and falls
how to sample urine from catfher
directly from catheter or from sample port using aseptic technique
not from bag
treat catheter associated uti
if symmtpoms antibioitcs 7 days
chage catheter soon as can
whats BPH
usually men over 50
hyperplasia of epithelial and stromal cells of prostate
presentation of bengin prostate hyperplasia
LUTS-
hesitancy
straining
weak flow
urgency
frequency
intermittency- flow start/stop and varies rate
terminal dribbling
incomplete emptyig- chronic retention
nocturia
investigations for bph
digital rectal exam
urine dipstick
PSA
abdo exam- palpate bladder?
urinary frequency volume chart - 3 days assess input and output
benign/cancer prostate on digital rectal exam
benign- smooth, round, regular, slightly soft, feel midline sulcus, symmetri cal
cancerous - firm/hard, asymetircla, craggt, irregulr, loss central sulcus
causes of rasied PSA
high rate of fasle posititves- 75%
false negatives 15%
rasied wih
prostate cnacer
BPH
prostatitis
vigorous exercise- esp cycling
ejaculation/prostate stimulation-anal sex
prsotate biopsy
uti
urinary catheter insertion
no ejactualtion/ vigorous exercise = 48 hrs before
after biopsy prostate/catheter inseertion- wait 6 weeks for psa test
management of bengin prostatic hyperplasia
non if mild/manageble
alpha blockers- Tamsulosin - rapid improvement symtpoms
se= postural ht
5-alpha reductase inhibitors - Finasteride - inhibits the 5 alpha reductase that converts tesoterone to DHT (stronger androgen) so helps shirnk prostate - 6 months for impromement of symtpoms se= erectile dysfunction
can use both meds together
surgery-
transurethral resection of the prostate
transurethral electrovcaporisation of the prostate
holmium laser enucleation of the prostate
open prostatectomy - abdo/perineal incision
complicaitons of surgery if bph
bleeding
infection
urinary incontience
erectile dysducntion
retrograde ejacualtion
urethral stricutres
may not reolse symtokms
male 60 patient comes in getting dixxy when stand up
what need chack
is he on tamsulosin = se is postrual hypotension as relaxes smooth muscle
check supine and standing bp
side effect of finasteride
sexual dysfucntion - reduced androgens
- loss libido
ejaculaiton issues
ed
etc
classes of prostatitis
acute bacterial prostatitis
chronic prostaitits (symtoms at least 3 months) = two categories for this :
chronic prostiatits/ chronic pelivc pain syndrome (cause may be due to intially infection then inflammation not resolve)
chronic bacterial prostatitis
presentation of prostatitis
LUTS - dysuria, frequency, retention, hestitancy
pelivc pain- can be sctorum, perineum, testicular, penis, rectum, lower back, groin, suprapubic pain
sexual dysfunction- ed, haematospemia, pain on ejaculation
pain on bowel movement
tneder/enlarged prostate- could be normla though
acute bacterial prostotos have more rapid onset symtpoms and aslo sytemic symtooms - fever, mylagia, sepsis, nasuea, fatigue
investigations for prostitis
urine dipstick- psotive in acute, may be postive with chronic bacterial but may not show unless got acute uti. use urine microscopy, culture, sneeitivity- psotive in chronic and acute bacterial prostaittis
digial rectal exam
abdo exam- bladder, genital exam
chlamydia, conhorrea NAAT testing if suspet sti
psa for chronic to rule out prsitate cancer
management acute bacterial prosatitis
hosp admission if systemically unwell - bloods. iv antibiotcs
oral antibiotcs 4-6 weeks first line: ciprofloxacin/ofloxacin (if not use these then trimethorprim)
anaglesia- nsaids/ paracetamol
laxatives to help pain on bowel movement
management of chronic prostatits
alpha blockers if signs of LUTS - tamsulosin -4-6 weeks= gives rapid improvmenet
anaglesia- paracetamol/nsaids
psycholgicxal- cbt/ anti depressants
abx if had less than 6 moths of symtpomd or if had hisotry of an infection = trimethoprim/doxycycline 4-6 weeks
laxatives if pain on bowel movement- lactulose/ docusate
where prostate cacer metasise to
lymph nodes
bones
featyrs of prostate cancer - where it growa, tyoe
almost always androgen dependant
most are adenocarcinomas and grow in peripheral zone
balance betqeen wanting to find cacner early but not pick up cancers that wouldnt be concerning - die before have prostate cancer symtpoms
risk factors prostate cancer
increased age
fam hist
black african/carribean
tall
anabolic steroids
obesity
presentation of prostate cancedr
can be asymtpomatic
may have luts same as BPH-
hestiacnt, frequency, weak flow, terminal dribbling, nocturia
haematuria
Erectile dysfunction
sighs of progressed cacer/metases- weight loss, bone pain, cauda equina
investigations
prostate cancer
pr exam- irregular, craggy, nodular, hard/firm, asymemetrocial, loss central sulcus = any these 2ww
firs tline after thayt is Multiparametric MRI of the prostate - do if susepcted localsied cancer
this gives likert scale 1 is v low suspicion 5 is definite cancer
then based on likert scale 3 or more/clinical suspicion do prosate biopsy
isotope bone scan - bony metasteses
prostat ebiopsy score used
gleason grading system -
1 closes to normal histology
use two number for the two most common cells
6 low risk
7 mid risk
8 or above high risk
risk biopsy
infection
pain- perineal, rectal, lower abdo
bleeding- in stool, urine, semen
urinary retention short term due to prosate swelling
mangement of prostate cancer
watch an wait
external beam radiotherapy
brachytherapy- insert radioactive metal seeds in prostate
hormone therpay
surgery- prostectomy
complications of external beam radioatherpy and how treat that complcation
can casue proctitis
= pain, altered bowel habit, rectal bleeding, discharge from rectum
treat with predinisolone suppository
complciation of brachytherapy
the radioactive can cause inflammation of other organs nearby- proctitis, cysittis
can casue ed and incontiencne. can in crease risk of bladder and rectal cancer
complication of prostatectomy
ed
urinary inconeitnce
hormone therpay treatment for prostate cancer
and se
aim reducde androgen
GnRH agonist - goserelin/ leuprorelin
androgen receptor blockers- bicalutamide
bilateral orchidectomy - rare to do but removing testicles
SE
hot flushes
fatigue
osteoporosis
gynaecomastia
sexual dysfucntion
what age can a man request a psa
over 50
wheres sperm stored and mature
epididmyis
causes of epididymo-orchirtis
e coli
chlamydia trachomatis
neisseria gonorrhea
mumps
pt has parotid gland swelling and orchtitis
what casue
mumps
if got parotid gland swelling and orchitits then suspect mumps
mumps tends to spare the epidiymius
mumps can also casue pacnreatitis
presetation of epididymoorchitits
relatively acute onset- mins to hrs
usulally unilateral
testicalu pain
tenderness on palpation - esp over epididmyis
dragging/ heavy sensation
swelling of testicle+/epididymis
urethral discharge - chlamydia/gonorrhea
systenic symptoms- n and v, fever, sepsus
what differential diagnosis for epididymoorchitis
testicular torsion- if unsure treat as this until proven diff
investigfations for epididymoorchitits
need to distinguish if sexually transmitted organism or if enteric organsim (e.coli)
urine microscopy, sensitivity and culutre
gonorrhea and chlamyida naat testing on first pass urine if suspect sti casue
charcoal swab of purulent urethral discharge for gonorrhea culture and sensitivities
saliva swab for pcr if mumps suspected
serum antibodies for mumps if suspected- IgM= acute infection, IgG= previous infection/vaccinated
ultrasound to asses torsion/tumour
when would you suspect sti the casue of epididymoorchitits
under 35
high number of sexual partnes in last 12 months
urethral discharge
management of epididymo orchitits
if v unwell/ sepsis- hosp for iv antibiotics
if risk of sti refer to GUM
if low risk sti casue then give ofloxacin 14 days - frist line
or levofloxacin 10 days
or if quinolones contraindicated give co amoxiclav
can give doxycycline
when are quinolones used - good for
broad spectrum abx
v good for gram negative
used for uti, pyeloneprhittis, epididymo orchitits, prostitis
se of quinolones
tendon damage/ rupture- esp achilles tendon
lower thresholf ofr seizures- be careful in epipleptic patients
qt interval prolongation
fungal infection
complications that epididymo orchitits can casue
chronic pain
chronic epididymitits
testicular atrophy
subfertility/infertitlity
scrotal abscess
whats testicular torsion
urological emergency
spermatic cord twists with the roation of the testicle- cuts of blood supply to testicle
male comes in with abdominal pain
what need to examine
testicles o exclude testicular torsion
causes of testicular torsion
often triggered by acittivty eg. playing sports
bell clapper deformity - testicle and tunica vaginalis not fixated together like normally should-> testicle hangs more horizontally and can rotate within the tunica vaginalis and twist the spermatic cord
presentation of testicular torsion
acute onset unilateral testicular pain
may have abdo pain and vomiting
!sometimes abdo pain is only symptom in boys!
o/e
swollen frim testicle
elevated/retracted testicle
absent cremasteric reflex
abnormla testicular lie- more horizontal instead of more vertical
rotation- epididymis not at usual posterior position
investigation for testicualr torsion
dont really
if examination and history suspect go straight to treatment as any delay can increase ishcemia and increase chance of necrosisi
can do scrotal us and see whirlpool sign = spiral appearance to spermatic cord and bv
management of testicualr torsion
urgent treatment
nil by mouth- ready fir surgery
analgesia
surgical exploration of scrotum
orchiopexy= correct postitioning of testicle and fixathion in place
orchidectomy- remove testicle if surgery is delayed/necrosis
when taking hisotry of testicualr pain what need ask
when did the pain start - testicualr torsion normally during activity
had it before - can have reoccurence where have intermittend testicualr torsion
causes of scrotal/testicular lump
testicular cancer
epididymo-orchitits
hydrocele
varicocele
epididymal cyst
inguinal hernia
tesiticular torsion
whats a hydrocele
collection of fluid in the tunica vaginalis
presentation of hydrocele
usually painless
soft scrotal swelling
transilluminated and see testicle floating
testicel palpable
soft, fluctuant and may be large
irreducible and no bowel sounds- differentiate from inguinal hernia
cause of hydroele
idiopathic
secodnary to:
testicular cancer
epididymo-orchitits
trauma
management of hydrocele
exclude serious cause
idiopathic- mangage conservcatively
if symptomatic/large= surgery/ aspiration/ sclerotherapy
whats varicocele in a testicle
and cause
veins in the pampiniform plexus that drains the testicle are swollen
pampiniform plexus drains the testicles and this plexus is in the spermatic cord. it helps regualte temp of testis as lies next to the testicular artery and so abosrbs heat from blood going into the testicle.
pampiniform plexus drains into the testicular vein
R testicualr vein drains into the IVC
L testicular vein drains into the L
renal vein
if theres increased resitance in the testicualr vein then have varicocele as blood cant exit the paminiform plexus/ if the valves in the testicualr vein are incompetant then blood flow back into the paminifrom plexus
which side is most comon for vcaricocele
left side varicoele are most common -90%
left sided varicoele can indicate what
renal cell carcinoma -
the left testicualt vein drains into the left renal vein. if theres an obstruction in the left testicualr vein that can be casued by renal cell carcinoma then back pressure and pampiniform plexus cant drain so varicocele
complications of varicoele
subfertility/inferitliy- temp not regualted
testicular atrophy- reduced size and function
presentation of testicualr varciocele
throbbing/dull pain worse on standing- gravity
dragging sensation
subfertility/infertility present with
o/e=
scrotal mass feels like bag of worms
more promintent on standing
disappears when liw down- if dont then concern for retroperitoneal tumour blocking the drainage of the renal vein L
asymmetry of testicle sizeaffected by growth
why if the scortal swelling of a testicular varicocele doesnt disparea on stadning be for concern
if its left then this suggest that theres retroperitoneal tumour blocking the drainage of the renal vein (l testicular vein drain into the l renal vein)
management of testicualr varciocele
conservativielt
surgery/endovascualr embolisation if pain/testricualr atrophy/ inferitltiy
investigfations for testicualr vcaricocele
us doppler for confrim dx
semen analysis if concern fertilit
hormonal test- fsh and testosterone if concern testicle function
whats an epididymal cyst
fluid filled sac on epididymis
whats a spermatocele
cysts containing semen on epeididymis - same mangaemt of epididmal cysts
presentaiton of epidiymal cyst
very common
mmost asyptomatic just feel lump
soft round lump
may be transillinate large cysts
normaly at head of epididymis (top of testicle)
associated with epididymis
seperate from testicle
can have torsion of cysts so acute pain and swelling but v rare
treatment epididymal cysts
usually harmless
if pain / discomfrot then reoval
what cells does most testicular cancer arise from
germ cells- make gametes
are other rarer ones and metasteses
types of testicular cancer
seminomas
non seminomas= mostly teratomas
risk factors of testicualr cacner
most common in young men 15-35 yrs old
undescended testes
male infertility
tall height
fam hist
presentation of testicualr cancer
painless lump
can have testicular pain
lumps is :
non tender may eve have decreased sesation
non fluctuant
irregular
non transillumination
hard
rarely can have gynaecomastia - esp in leydig cell tumour
investifations for testicualr cancer
scrotal us - first line for diangosis
tumour markers-
alpha fetoprotein= may be raised in teratomas
beta hCG - may be rasied in teratomas and seminomas
LDH(lactate dehydrogenase) = non specific tumour marer
staging CT
what staging system is used for testicualr cacner
royal marsden staging system
1= isolated to tesicle
2= lymoh nodes retroperitoneal
3=lymph nodes under diagphrgm
4= metasitise to other organs
where are the common palces testicualr cancer can metastisie to
brain
liver
lungs
lymphatics
managemnt of testicualr cacner
surgery- orchidectomy - can have prosthetis
chemo
radiotherpy
sperm banking- rx may casue infertility
long term side effects of testicualr cancer treatment
big impact as men young and expected to live long after treatment
hearing loss
peripheral neuropathy
infertility
renal lung and heart damage
increase risk of cancer in furtutre
hypogonadism= may need testosterone replacmeent
prognosis and what to do once treated with testicualr cancer
good prognosis for testicualr cacner esp if eaerly 90% cure. even metastatic is curable. seminomas slightly better prognosis
monitor for reoccurenace- ct, tumour markers, cxr
whats a lower urinary tract infection
infection of bladder casuing cystitis
can spread up to kidneys and cause pyelonephritits
risk factors lower uti
Sex
woman
poor hygiene
incontinence
urinary catheter
casues of lower uti
e coli!!! = gram negative, anerobic, rod shaped
klebsiella pneumonia
pseudomonas aerguinosa
staphylcoccus saprophyticus
candida albicans- fungal
resentation of lower uti
dysuria- pain, burning, stinging on passing urine
frequency
urgency
incontinece
cloudy/foul smelling urine
suprapubic pain/discomfort
haematuria
confusion! - esp aelderly frail only symtpoms sometimes
hpw to know difference to lower uti and pyelonephritis
pyeloneprhtitis susepct if :
fever
loin/ back pain
renal angle tenderness on examaintion
nausea and vomiting
investigations for lower uti
urine dipstick
mid stream sample for microscopy, sensitivity and culutre if :
pregnant
pt with recurrent uti
atypical symtoms
not improing after abx
nitrites
uti treat
gram negfative bacteira convert nitrates to nitrites
leucoytes
treat uti if got clinical signs
leukocytes and rbc
treat uti
nititires and lekocytes
treat uti
rbc in urine mean
uti
bladder cancer
nephritits
leukocytes in urine mean
infection
other cause of inflammation-
treat uti with
nitrofurantoin - not if eGFR under 45
trimethorpim
other:
pivmecillinam
amoxicillin
ciprofloxin
3 days if simple uti women
5-10 days if immunosupressed woman, abnormal anatomy, impaired renal funnction
7 days man, pregant woman, catheter uti = and change catheter
treatment for pregnant women uti
uti increase ris of pyelonephrotits, premature rupture of membranes, pre term labour
do MSU for cutlure and microscopy and sensititivites
7 days abx: nitrofurantoin (not 3rd trimester as casue neonatal haemolysis)
amoxicillin if senstivies say
cefalexin
try an avoid trimethoprim most times but defo dont give it in forst trimester as its a folate antagonist so will casue congenital malformations - spina bfidia
lady
immunsupressed
uti
treatment
5-10 days antibiotcs
nitrofurantoin
trimethoprim
pivmecillinam
amoxicillin
cefalexin
pregnat lady
2nd trimester
uti
treamtnet
nitrofurantoin can be given as not in 3rd trimester
7 days
msu for culture and microscopy and sensitivties
when not to give nitrofurantoin to pregnant lady for uti
not in 3rd trimester as causes neonatal haemolysis
when to not give trimethoprim to pregnant lady with uti
not in frist trimester as casue congential malformation as folate antagonist - spina bfida
try to not give it at all though
whats pyelonephritits
inflammation of the kidney die to bacterial infection that casues inflammation of the renal pelvis and parenchyma
risk factors of pyelonephritits
pregancy
diabetes
female
structural urological abnormalities
vesico-ureteric reflux= usually childrne
casues of pyelonephritits
e.coli- gram negative , rod shaped anerobic
klebsiella pneumoniae
staphylcoccus saprophyticus
psuedomonas aeurogniosa
enterococcus
candida albicans= fungal
dysuria
suprapubic disconfort
fever
vomiting
loin pain
what is this
pyeloneprhtitis
presentation of pyeloneprhtitis
luts-
dysuira, suprapubic disomfort, increased frequency
plus triad of:
fever
n/v
loin/back pain- unilateral/bilateral
can also have:
systemic illness
loss appepties
haemoaturia
renal angle tenderness o/e
investigfations for pyelonepthritits
urine dipstick=nitrites, leukocytes, blood
msu for microscopy, sentivies and culture
bloods- raised wbc and crp
us/ct scan for other pathologies= kidneys stones/abscess
management of peylonephritits
hosp if sepsitis features
antibiotics 7-10 days
cefalexin
co-amoxiclav - if culture results available
trimethorpim- if culture resutls available
ciprofloxacin= se are tnedon damage and lower threshold seizures
if sepstic:
sepsis 6
- blood lactate
- blood culture
- monitor urine output
- give oxygen sats aim 94-98% (88-92% copd)
- iv fluids
-iv broad spectrum abx
if patient on abx for peylonepthritis not improving consider what
renal abscess
kidneys stone obstructing ureter causing pyelonepthritis
whats chronic peylonepthritis
recurtrent epidosdes of pyelonephritits
–>
recurrent infections causes scaring of parenchyma –> cks–> end stage renal fialure
what investifation do for chronic pyelonephritits
DMSA scan (dimercaptosuccinic acid)
inject radiolabeled DMSA
healthy kidney takes it up- scarred/ damage areas dont take it up
can see gamma camera areas of scarring
whats interstitial cystitis
also called hypersentive bladder syndrome / bladder pain syndrome
chronic condition causing inlfammation of bladder resulting in LUTS and suprapubic pain
presentation of interstitial cystits
more common in women
similar to lower UTI but more persitiant
usually over 6 weeks of: suprapubic pain- can be worse on full bladder and relived on emptying frequency
urgency
symtoms may be worse during menstruating
inverstivations interstital cystitis
exclude other casues
urinalysis - uti
cystosctopy= bladder cancer
swabs - sti
prostate exam- cancer, prostatits, bph
what see on cystoscopy in interstital cystitis
hunner lesions = red, inflammed pathces of bladder mucosa 5-20% have
granulations- tiny haemorrhages on bladder wal
management of interstital cystitis
supportive:
diet - no alcohol, caffeine and tomatoes
stop smoking
cbt
retrain bladder
pelivc floor exercises
TENS
meds:
analgesia
antihistamine
anti cholinergics- solefenacin, oxybutynin
mirebegron= beta 3 adrenergic agonsit
cimetidine- histamine 2 r antagonist
pentosan polysulfate sodium
ciclosporin- immunsupressant
intrevesical meds- directly to bladder:
lidocaine
pentosan polysulfate sodium
hyaluronic acid
chondroitin sulphate
hydrodistention- GA fill bladder with water to high pressure - temorary improve symtoms 3-6months
surgical:
cauterisation of hunner lesions - cystoscopy
butulinum toxin injections during cystoscopy
neruomodulation with implanted electrical stimulator
augmentation of bladder using section of iluem to increase capacity= ileocystoplasty
cystectomy
patient presents with lUTS
differentials
lower UTI
pyelonephritits
interstital cystitis
where does bladder cancer arise from
urothelium- epithelial cellsof bladder
risk factors bladder cancer
increased age
smoking
aromatic amines- in rubber and dye now bannned/regulated - in cigarettes too = its a carcinomgen for bladder cancer
schistosomiasis= casues squamous cell carinoma in countries of high prevelance of infection
patient painless hameaturia and worked in rubber facotry
bladder cnacer
types of bladder ancer
transistional cell carcinoma=90%
squamous cell carcinoma= 5% but higher in areas of schistosomasis
tohers:
small cell carcinoma, adenocarcioma, sarcoma
preentation bladder cancer
when do 2 ww
painless haematuria]
over 45 and unexplained macroscopic haematuria without uti / uti presisting after rx
over 60 and microscopic haematuria and dysuria/ raised wbc on fbc
over 60 with recurrent unexplained uti
non urgent referal to check bladder cancer
diangosis of bladder cancer
cycstoscopy
staging:
non invasive muscle bladder cancer = Tis (cancer cells in urothelium and flat)
ta= urothelium and proturde into bladder
t1= into the connective tissue but not muscle
invasive bladder cxancer- T2-4
treatment of bvladder cancer
chemo / radiothepry
transurethral resection of bladder tumour - for non muslce invasive cancer - during cystoscopy
intravesical chemo
intravescial BCG(same vaccine TB) - stimulates immunsystem to attack bladder caner
radical cystectomy
whats the ways urine can drain out once had a cystectomy
urostomy with ileal conduit = most common- use secion of the ileum (anastamose the bowel back together). anatsamose the urethers to the ileal section and then the ileum forms a stoma on the skin draining into a urostomy bag - bag needs be away from skin as urine irritate and damage the skin
continet urinary divcersion- use ileum as above but no urostomy bag so doesnt drain freely have to insert catheter intermittently into stoma to drain the urine fromthe ileal pouch
neobladder reconstruction- use section of ileum and connect urethers and urethra to it - may need washouts to clear the ileal secretion
uretersigmoidostomy - ureters into sigmoid and create a rectosigmoid puch for urine to stay in and then open bowels and urine will aslo come out - not used much now as electroylte imbalance, infection of kidneys and secondary cacer at the uether and sigmoid anastamoses
names for kidney stones
renal calculiculi
urolithiasis
nephrolithiasis
key complications of kidney stones
obstruction leading to aki
infection with obstructive pyelonephrittis
common place kideys stones get stuc
vesicouteric junction
types kidneys sotnes
calcium based= most common
- calcium oxalate - more common
- calcium phosphate
uric acid - not seen on xray
struvite- produced bby bacteria = assocaited with infection
cystine - associated with cystinuria - autosomal recessive disease
whats staghorn calciculi and common stone made of
form in shape of renal pelvis
may be seen on xray
most commonly occurs with struvite stones
occur in reccurent upper uti as bacteria hydroylse the urea to amonia
presentation of kidney stones
can be asymptomatic and cause no priblesm but if symtpomatic :
renal colic:
- unilateral loin to groin pain and can be excruiciating
- colicky pain- fluctating severity as stone moves
can also have :
reseltess moving due to pain
haematuria
nausea and vomiting
decreased urine output
symptos of sepsis if present
investigfations for renal stones
first line: non contrast CT of bladder, ureters and kidneys - try do within 24 hrs of presentation
urine dipsick may show haematuriea- if normal doesnt exclude stone
bloods- serum ca, raised infpam if infection, see kidney funciton
abdo xray - see ca based stones
us - less effective but good if children/ pregant women
managemen tof renal stones
nsaids- rectal/oral diclofenac
antiemetics- metoclopramide, cyclozine, prochlorperazine
abx if infection
watch and wait if less than 5mm - can use tamulosin to help (alpha blocker )
surgical intervention if larrge 10mm or more or if not passing or if complete obstruction
surgical interventions:
extracorporeal shock wave lithotripsy
ureteroscopy and laser lithotripsy
percutaneous nephrolithotripsy - done under GA
open surgery
what can you do for patientshtat have recurrent stones
adivse:
increas fluid oral intake 2.5-3l/day
fresh lemon juisce to water as helps bind to ca in urine
avoid carbonated drinks - promotes oxalate formation
decrease salt intake
maintain normal ca intake - low ca can actually promote ca stones
limit diet protein
ca stones:
reduce oxalate rich foods= beetroot, nuts, spinahc, rhubarb, black tea
uric acid stones:
reduce purine rich foods=
liver,kidneys, spinach, anchovies, sardines
meds to reduce recurrence:
thiazide dieuretics (indapomide) = forpatients with ca oxalate stones and high urine ca
potassium citrate = ssame as above
risk facotrs of ca stones
hypercacliumea
low urine output
casue sof ca stones
high ca:
hyperparathryoidsim
ca supplementation
cancer
types of renal cell carcinoma
renal cell carcinoma is a type of adenocarcinoma
renal cell carcinoma is the most common type of kideny tumour
types of renal cell adenocarcioms:
clear cell- 80%
papillary-15%
chromophobe -5%
wilms tumour is a specific type of tumour seen in childrentypicallt under 5
risk factors renal cell carcinoma
obesity
smoking
hypertension
end stage renal failure
con hippel lindau disease
tuberous sclerosis
haematuria
flank pain
palpable mass of kideny on oe
renal cell carcinoma
presentation of renal cell carcinoma
haematuria
flank pain/ vague loin pain
palpable mass o/e
can be asymptomtic
weight loss
dec apeptie
night sweats
fatigue
can also get paraneoplastic features
when do 2 ww for renal cell carcinoma
over 45 with visible haematuria without uti/presitant uti depsite rx
where does renal cell carinoma spread to
tissues around kidney and withi in the gerotas fascia
renal vein to ivc
feature of renal cell carinoma on cxr of lungs
cannonball metastases
= cleary defined circular opacities scattered throughout lung fields in cxr
whats cannonball metases in lungs a featre of
renal cell carcinoma
can also be a feature of choriocarcinoma (placental cacner)
and less commonly in prostate, bladder and endometrial cancer
whats the paraneoplastic features that can be associated with renal cell carcinoma
hypercalcaemia - hormone secreted similar to PTH - can also be due to bony metastes
hypertension- physical compression, increased secretion of renin, polycythaemia
polycythamia = due to increased unregulated secretion of erythropoeitin= increased risk thrombosis
stauffers syndrome - raised LFTs- raised alt, ast, alp, billirubin without liver metastases
satging renal cell carcinoma how to
ct thorax abdo and pelivs
management of renal cell caricnoma
partial nephrectomy
radical nephrectomy
if not suitable for surgferu:
arterial embolisation- cut off blood supply to affected kidney
percutaenous cryotherpay- liquid nitrogen injected to freeze and kill tumour cells
radiofrequency ablation
chemo/radiotherpay
patient has renal failure
has suspected pe
investigation
vq scan - not ctPA cus that has contrast in
posotives of renal transplant
adds 10 years life compared to dialysis
improves q of l
donot matching for renal transplant
match HLA on chr 6
if donor alive can desensitise pt to their hla
doesnt have to match perfect, but better match the better chance working and no rekection
pt had renal transplasnt
what can you see on them in an examination
brachio-cephalic av fistual - left in for dialysis if needed again
hockey stick scar in iliac fossa area
may be able to palpate kidney in iliac fossa
if ballot the pt own kidneys if enlarge may feel them if their pathology casues them to be
seborrheic warts = due to immunosupressants
skin cancer/scxar from skin cacner removeal= due to immunosupressant s
gum hypertrophy- due to cyclosporine - option of immunsupressant
cushing syndrome - due to steroids
tremor- due to tacrolimus
procedure of renal transplant
leave kideys in place
put new kideny in iliac fossa with hockey stick incsiion
connect donor kidney bv to pelivic vessels- external iliac vessels
ureter of kidey anatstamosed to bladder
treatment for after renal transplant
immunosuprresants life long :
tacrolimus
prednisolone
mycophenolate
= usual regime
others:
cyclosporine
azathioprine
sirolimus
se of the immunosuprresants on for rneal transplant
tacrolimus= tremor
immuosuppresants= seborrheic warts, skin cancer (esp squamous cell carcinoma)
predinosolone= chsuhings syndrome
cyclosporine = gum hypertrophy
complications of renal transplant
transplant:
rejection- hyperacute, acute, chronic
failure
electroylte imbalance
immuosupressants :
ifection- more likely, more severe, unusal
skin cancer- squamous cell carcinoma
non-hodgkin lymphoma
ischemic heart disease
type 2 diabetes- due to steroids reducing bodys senstivity to insulin (cant take up glucose into cells so need more insulin= insulin resistance)
infections secondary to immunosupresants
what infections are secondary to immunosupressants esp i renal treansplant
cmv= cytomegalovirus
pcp/pjp= pneumocytits jiroveci pneumoniaE
TB
