Urology Flashcards
1
Q
What procedure may be performed during a cystoscopy to remove a non-muscle-invasive bladder cancer? (1)
A
Transurethral resection of bladder tumour (TURBT)
2
Q
Name an androgen receptor blocker used in the treatment of prostate cancer. (1)
A
Bicalutamide
3
Q
What treatment for kidney stones involves a camera inserted via an incision in the back, through the kidney and into the ureter, allowing the stones to be broken into small pieces and removed? (1)
A
Percutaneous nephrolithotomy
4
Q
Where does fluid collect when a patient has a hydrocele? (1)
A
Within the tunica vaginalis
5
Q
What are the two main risk factors for calcium-based kidney stones? (2)
A
- Hypercalcaemia
- Low urine output
6
Q
What is the National Institute of Health Chronic Prostatitis Symptom Index used to assess? (2)
A
- The severity of their symptoms
- and their impact on quality of life in chronic prostatitis.
7
Q
What investigation can be used to establish the causative organism in acute bacterial prostatitis? (1)
A
Urine MC&S
8
Q
What paraneoplastic syndrome is associated with excessive unregulated erythropoietin production? (1)
A
Polycythaemia
9
Q
What is the most common long-term solution for draining urine after a radical cystectomy? (1)
A
Urostomy
10
Q
What is the risk and consequence of a delay in diagnosing and treating testicular torsion? (2)
A
- Ischaemia and necrosis of the testicle
- Leading to sub-fertility or infertility
11
Q
What term describes the over or under-activity of the detrusor muscle of the bladder that may occur in multiple sclerosis? (1)
A
Neurogenic bladder
12
Q
What scoring system is specific to prostate cancer and helps to determine what treatment is most appropriate? (1) What result is the score based on? (1)
A
- Gleasdon grading system
- Histology from the prostate biopsies
13
Q
What medication can be used to relax smooth muscle and improve symptoms in patients with chronic prostatitis? (1)
A
Alpha blockers e.g. tamsulosin
14
Q
What procedure involves correcting the position of a testicle and fixing it in place? (1)
A
Orchiopexy
15
Q
What findings might be seen on cystoscopy in patients with interstitial cystitis? (2)
A
- Hunner lesions
- Granulations
16
Q
What is now the usual first-line investigation for suspected localised prostate cancer? (1)
A
Multiparametric MRI of prostate
17
Q
Foods rich in what compound increase the risk of calcium-based kidney stones? (1)
A
Oxalate
18
Q
What scoring system can be used to assess the severity of lower urinary tract symptoms in benign prostatic hyperplasia? (1)
A
International Prostate Symptom Score (IPSS)
19
Q
What operation typically requires a “hockey-stick” incision? (1)
A
Renal transplant
20
Q
Which side are most varicoceles on? (1) Why? (1)
A
- Left
- because increased resistance in the left testicular vein as it drains into the renal vein whereas the right testicular vein drains directly into the vena cava.
21
Q
What are the four most common areas for testicular cancer to spread? (4)
A
- Lymphatics
- Lungs
- Liver
- Brain
22
Q
What are the main tumour markers for testicular tumours? (2)
A
- Alpha fetoprotein (AFP)
- Beta-HCG
23
Q
What medication can be given directly into the bladder as a form of immunotherapy, as part of the treatment of non-muscle-invasive bladder cancer? (1)
A
BCG vaccine (Bacillus Calmette-Guerin)
24
Q
What class of recreational drug increases the risk of prostate cancer? (1)
A
Anabolic steroids
25
What features would make you suspect pyelonephritis rather than a lower urinary tract infection? (4)
1. Fever
2. Loin/back pain
3. Nausea/vomiting
4. Renal angle tenderness
26
What may be added to water to reduce the risk of kidney stones? (1)
Lemon juice
27
Which chemicals previously used in the dye and rubber industries are a key risk factor for bladder cancer? (1)
Aromatic amines
28
What is the investigation of choice in suspected bladder cancer? (1)
Cystoscopy
29
What is the most common cause of a soft, round lump at the top of, but separate from, the testicle? (1)
Epididymal cyst
30
What finding on a urine dipstick test is most suggestive of infection? (1)
Nitrites
31
How long do symptoms need to be present to diagnose chronic prostatitis? (1)
3 months
32
What chemical in carbonated drinks promotes calcium oxalate formation in the kidneys? (1)
Phosphoric acid
33
What is the classic triad of presenting features in renal cell carcinoma? (3)
1. Haematuria
2. Flank pain
3. A palpable loss
34
What venous plexus swells in patients with a varicocele? (1) What does this directly drain into? (1)
1. Pampiniform plexus
2. Testicular vein
35
What staging system is used for testicular cancer? (1)
Royal Marsden (stage 1-4)
1: isolated to testicle
2: spread to retroperitoneal lymph nodes
3: spread to lymph nodes above diaphragm
4: metastasised to other organs
36
What is the most common surgical treatment for benign prostatic hyperplasia? (1)
Transurethral resection of prostate (TURP)
37
What existing medical condition would prevent you prescribing a quinolone antibiotic? (1) Why? (1)
1. Epilepsy
2. Lowers seizure threshold
38
What significant adverse effect should you warn an otherwise healthy patient about when prescribing quinolone antibiotics? (1)
Tendon damage/rupture
39
What is the most common site of prostate cancer metastasis? (1)
Bone
40
What cause of orchitis might be associated with pancreatitis and parotid gland swelling? (1) How might you test for this? (1)
1. Mumps
2. Salivary swab for PCR
41
What is the most common histological type of bladder cancer? (1)
Transitional cell carcinoma
42
What common skin lesions might suggest a patient is taking long-term immunosuppressants? (1)
Seborrhoeic warts
43
What infection is a risk factor for bladder cancer? (1)
Schistosomiasis
44
What options can be used to bypass a lower urinary tract obstruction, such as a urethral stricture? (2)
1. Urethral catheter
2. Suprapubic catheter
45
Give two key complications of a radical prostatectomy. (2)
1. Erectile dysfunction
2. Urinary incontinence
46
What treatment involves implanting radioactive metal “seeds” into the prostate? (1)
Brachytherapy
47
What intervention can be used to bypass an upper urinary tract obstruction? (1)
Nephrostomy
48
What is the definitive investigation for establishing a diagnosis of prostate cancer? (1)
Biopsy
49
What is the typical first line treatment for epididymo-orchitis in patients that are low risk for STIs? (1)
Ofloxacin
50
What type of testicular tumour can cause gynaecomastia? (1)
Lydia cell tumour
51
What is the risk of not replacing the foreskin after inserting a urinary catheter in a man? (1)
Paraphimosis
52
What characteristic examination finding can suggest a patient takes tacrolimus? (1)
Tremor
53
What finding on a chest x-ray is suggestive of metastatic renal cell carcinoma? (1)
Canonball metastases
54
What type of kidney stones cannot be seen on an x-ray? (1)
Uric acid stones
55
What treatment for interstitial cystitis involves filling the bladder with water, to high pressure, during a cystoscopy? (1)
Hydrodistension
56
What characteristic examination finding can suggest a patient takes cyclosporine? (1)
Gum hypertrophy
57
What class of medication are goserelin and leuprorelin examples of? (1)
GnRH agonists
58
What medication can be used to help aid the spontaneous passage of kidney stones? (1)
Tamsulosin/alpha blockers
59
What is a notable side effect of tamsulosin? (1)
Postural hypotension
60
What are the three main causes of hypercalcaemia? (3)
1. Calcium supplements
2. Hyperparathyroidism
3. Cancer
61
What two groups can testicular tumours be broadly categorised into? (2)
1. Seminoma
2. Non-seminoma (mostly teratomas)
62
Foods rich in what compound increase the risk of uric acid-based kidney stones? (1)
Purine
63
What is the characteristic symptom of kidney stones? (1)
Renal colic
64
What sign may be seen on an ultrasound in testicular torsion?
Whirlpool sign
65
What two classes of medication can be used to treat benign prostatic hyperplasia? (2) Give one example of each.(2)
1. Alpha-blockers e.g. tamsulosin
2. 5-alpha reductase inhibitors e.g. finasteride
66
What unusual opportunistic infections can occur secondary to immunosuppressant medications? (3)
1. Pneumocystis jiroveci pneumonia
2. Cytomegalovirus
3. TB
67
What are staghorn calculi most often made of? (1)
Struvite
68
What examination finding should raise suspicion of a retroperitoneal tumour in a patient with a varicocele? (1)
Doesn't disappear when lying down
69
What is the most common reason for avoiding nitrofurantoin? (1)
eGFR < 45
70
What abnormality in the scrotum increases the risk of testicular torsion? (1)
Bell clapper deformity
Normally the testicle is fixed posteriorly to the tunica vaginalis. In a bell clapper deformity, fixation between the tunica vaginalis and the testicle is absent so it hangs in a horizontal position
71
What is the name for when urine is able to reflux from the bladder back into the ureters? (1)
Vesicoureteral reflux
72
What is the most effective form of analgesia for treating pain associated with kidney stones? (1)
NSAIDs
73
Where in the prostate is PSA produced? (1)
Epithelial cells
74
What duration of antibiotics is used in pyelonephritis for patients suitable for management in the community? (1)
7-10 days
75
When should nitrofurantoin be avoided in pregnancy? (1) Why? (1)
1. Third trimester
2. Risk of neonatal haemolysis
76
What term describes a blockage to urine flow along the urinary tract? (1)
Obstructive uropathy
77
What term describes swelling of the kidneys secondary to obstruction to the outflow of urine? (1)
Hydronephrosis
78
What cells give rise to most testicular cancers? (1)
Germ cells
79
What would a fluctuant mass on examination of the prostate indicate? (1)
Prostate abscess
80
How is CKD staged?
Stage 1 = >90
Stage 2 = 60-89
Stage 3 = 30-59
Stage 4 = 15-29
Stage 5 = <15
81
What are signs of CKD?
Pallor
Purpura
Bruising
Peripheral oedema
Proximal myopathy
82
What is the principle of dialysis?
Blood and dialysis fluid flow either side of a semipermeable membrane, molecules diffuse down their own concentration gradients so that blood becomes more like the dialysis fluid
83
What are complications of peritoneal dialysis?
Bacterial peritonitis
Infection around catheter site
Constipation
Failure
Sclerosing peritonitis
84
After how long is a transplant rejection chronic and not acute?
6 months
85
Why should transplant recipients be seen annually by a dermatologist?
Increased risk of skin cancer due to immunosuppression
86
What are the actions of PTH?
Increase osteoclast activity
Increased calcium reabasorption via the kidney
Increased hydroxylation of vitamin D
87
Is calcium high or low in tertiary hyperparathyroidism?
High
88
Is PTH high or low in tertiary hyperparathyroidism?
High
89
What are the pre-renal causes of AKI?
Hypovolaemia
Renal artery stenosis
Sepsis
Congestive cardiac failure
Cirrhosis
NSAIDs
ACE-inhibitor
90
What are the renal causes of AKI?
Acute tubular necrosis
Nephrotoxins (drugs, contrast, rhabdomyolysis, myeloma)
Glomerulonephritis
Vasculitis
Haemolytic uraemia syndrome
Malignant HTN
TTP
Cholesterol emboli
Pre-eclampsia
91
What are the post-renal causes of AKI?
Prostate cancer
BPH
Renal calculi
Renal tumours
Ureteric tumours
92
What are the life-threatening complications of AKI?
Hyperkalaemia
Haemorrhage
Pulmonary oedema
93
What are indications for dialysis in AKI?
Refractory pulmonary oedema
Refractory hyperkalaemia
Severe metabolic acidosis
Uraemic encephalopathy
Uraemic pericarditis
94
How does rhabdomyolysis cause AKI?
Acute tubular necrosis
95
What urine test confirms rhabdomyolysis?
Urinary myoglobin
96
What is seen on urine microscopy in rhabdomyolysis?
Muddy brown clasts
97
What are risk factors for rhabdomyolysis?
Immobilisation
Excessive exercise
Crush injuries
Burns
Seizures
Neuroleptic malignant syndrome
Drugs (heroin, statins, ecstasy)
98
What are the ECG changes in hyperkalaemia?
Tall tented T waves
Flat p waves
Prolonged PR
Widened QRS
99
How do you treat hyperkalaemia with ECG changes?
10ml calcium glutinate 10% over 5 minutes
IV insulin + dextrose
Salbutamol nebulisers
100
What test confirms Wegener's granulomatosis?
Renal biopsy
101
How is nephrotic syndrome defines?
Protein >3g/24 hours
Hypoalbuminaemia <30
Oedema
102
What is the most common cause of nephrotic syndrome in adults?
Membranous nephropathy
103
What are the complications of nephrotic syndrome?
Increased susceptibility to infection
Increased risk of thromboembolism
Hyperlipidaemia (treat with statin)
104
What is the dietary advice for nephrotic syndrome?
Normal protein intake
Restrict salt
105
What causes an upper obstructive uropathy?
Kidney stones
Tumours pressing on ureters
Ureter strictures
Ureterocele
Bladder cancer blocking the ureteral openings to the bladder
106
What causes a lower obstructive uropathy?
BPH
Prostate cancer
Bladder cancer
Urethral strictures
Neurogenic bladder
107
What is the pain in upper tract obstruction?
Loin to groin or flank pain (due to stretching of the ureter and kidneys)
108
Why might a mass be felt in the kidney area?
PKD
Hydronephrosis
109
What are the management options for hydronephrosis?
Percutaneous nephrostomy (inserted into ureters)
Anterograde ureteric stent (inserting a stent through the kidney into the ureter under radiological guidance)
110
What is enlarged in BPH?
Hyperplasia of the stromal and epithelial cells of the prostate
111
What are LUTS?
Hesitancy
Weak flow
Urgency
Frequency
Intermittency
Straining
Terminal dribbling
Incomplete emptying
Nocturia
112
How is BPH/prostate cancer investigated?
PSA
PR
Abdominal examination
Testicular examination
Urinary dipstick
Bladder scan to look for retention
Multiparametric MRI
Biopsy
113
How do alpha blockers work in BPH?
Relax smooth muscle
114
What is the mechanism of action of 5 alpha reductase inhibitors?
Blocks the enzyme that converts testosterone to dihydrotesterone (more active form). Can take up to 6 months
115
What is the main SE of alpha blockers e.g. tamsulosin?
Postural hypotension
116
What is the main SE of finasteride?
Sexual dysfunction due to reduced testosterone
117
What are complications of a TURP?
TURP syndrome (when irrigation fluid enters the systemic circulation): HTN, low BP, altered mental state
Urinary incontinence
Sexual dysfunction
Retrograde ejaculation
Urethral strictures
Hyponatraemia
Fluid overload
Glycin toxicity
118
What are alternatives to a TURP?
Transurethral electrovaporisation of the prostate
Holmium laser enucleation of the prostate
Open prostatectomy
119
What is the most common pathogen in prostatitis?
E.Coli
120
What bowel associated symptom do you get with prostatitis?
Pain with bowel movements
121
What medication treats prostatitis?
Oral for 2-4 weeks e.g. ciprofloxacin, ofloxacin, trimethoprim
122
How is chronic prostatitis managed?
Alpha blockers e.g. tamsulosin
Analgesia
CBT+/- antidepressants
Antibiotics if < 6 months (trimethoprim/doxycyline for 4-6 weeks)
Laxatives for pain with bowel movements
123
Where does prostate cancer most commonly grow?
Peripheral zone of the prostate
124
What is the most common type of prostate cancer?
Adenocarcinoma
125
What are the management options for prostate cancer?
Watchful waiting if early
External beam radiotherapy (proctitis is a complication)
Bracytherapy (proctitis and cystitis are complications)
Hormone therapy
Surgery (radical prostatectomy with aim to cure)
126
What are the hormone options used to treat prostate cancer?
Androgen receptor blockers e.g. bicalutamide
GnRH agonists e.g. goserelin, leuporelin (co-prescribe anti-androgen due to risk of tumour flare)
Bilateral orchidectomy
Used in combination with radiotherapy or alone where cure is not possible
127
What are the SE of hormone therapy in prostate cancer?
Hot flushes
Sexual dysfunction
Gynaecomastia
Fatigue
Osteoporosis
128
What are common causes of a raised PSA?
Prostate cancer
BPH
Prostatitis
UTI in last 4 weeks
Vigorous exercise (notably cycling) in last 48 hours
Recent ejaculation or prostate stimulation) in last 48 hours
Prostate biopsy in last 6 weeks
DRE in last week
129
What happens to the central sulcus in prostate cancer?
It is lost
130
How is mulitparametric MRI graded?
Likert scale
1 = very low suspicion
2 = low suspicion
3 = equivocal
4 = probable cancer
5 = definite cancer
131
What are the options for a prostate biopsy?
Transurethral ultrasound guided biopsy (in rectum)
Transperineal biopsy
132
What are the complications of a prostate biopsy?
Pain
Infection
Bleeding
Urinary retention due to short term swelling of the prostate
Erectile dysfunction
133
What scan is used to look for bony metastases in prostate cancer?
Isotope bone scan/ radio nucleotide scan/ bone scintigraphy
134
How is prostate cancer graded?
Gleason
Addition of the two most common histological patterns
135
What are the common causes of epididymo-orchtis?
E. Coli
Chlamydia trachomitis
Neisserie gonorrhoea
Mumps
136
What does the epididymis drain into?
Vas deferens
137
What is the onset of epididymal-orchitis?
Gradual
138
What microbial cover do quinolones give?
Gram negative
139
What are the two main SE of quinolones?
Reduces seizure threshold
Tendon damage and tendon rupture
140
What is the treatment for E.Coli epidimyo-orchitis?
Ofloxacin 14 days
Levofloxacin 10 days
Co-amoxiclav 10 days where quinolones CI
141
What is the treatment for STI epididymo-orchitis?
IM ceftriaxone single dose
Doxycycline
Ofloxacin
142
What is testicular torsion?
Twisting of the spermatic cord with rotation of the testicle
143
What shows on examination in testicular torsion?
Firm swollen testicle
Elevated (retracted testicle)
Absent cremasteric reflex
Abnormal testicular lie (often horizontal)
Rotation so that epididymis is not in normal position
144
What is the management of testicular torsion?
Nil by mouth
Analgesia
Urgent senior urology review
Surgical exploration of scrotum
Orchiopexy: correcting the position of the testicles and fixing then in place
Orchidectomy: removing the testicle if surgery is delayed or there is necrosis
145
What is the investigation of choice for testicular torsion?
Scrotal US: whirlpool sign
146
What causes a hydrocele?
Idiopathic
Secondary to:
Testicular cancer
Testicular torsion
Epididymo-orchitis
Trauma
147
What are the examination findings for a hydrocele?
Not separate from testicle
Irreducible and has no bowel sounds (distinguish from hernia)
Transilluminated
Testicle generally palpable
Soft, fluctuant
148
What is the management of large hydroceles?
Surgery
Aspiration
Sclerotherapy
149
What is the role of the pampiniform plexus?
Absorbs heat from the nearby testicular artery so the testicle is optimum temperature for producing sperm
150
Why do varicoceles occur?
Increased resistance in the testicular vein (where the pampiniform plexus drains into)
151
When is a varicocele more prominent?
On standing
152
When does a varicocele raise concern for a retroperitoneal tumour?
When it does not disappear on lying down
153
What is the investigation for a varicocele?
US with Doppler
154
How does varicocele cause infertility?
Disrupting the temperature regulation
May result in testicular atrophy, reducing the size and function of the testicle
155
What is an epididymal cyst that contains sperm called?
Spermatocele
156
What are the two types of testicular cancer?
Seminomas
Non-seminomas (mostly teratomas)
157
Which cells do testicular cancer arise from?
Germ cells (cells that produce gametes)
158
What are risk factors for testicular cancer?
Undescended testes
Male infertility
Family history
Increased height
159
Which rare testicular tumour presents with gynaecomastia?
Leydig cell tumour
160
What lump is found on examination with testicular cancer?
Non-tender (may even have reduced sensation)
Arising from the testicle
Hard
Irregular
Not fluctuant
No transillumination
161
What is the diagnostic investigation for testicular cancer?
Scrotal US
162
What are the tumour markers for testicular cancer?
Alpa fetoprotein (raised in teratomas but not pure seminomas)
Beta-hCG (may be raised in both)
Lactate dehydrogenase (very non specific)
163
What is management of testicular cancer?
Radical orchidectomy and prosthesis
164
Why are nitrites best to look for on dipstick?
Gram negative bacteria e.g. E.Coli break down nitrates into nitrites
165
What type of bacteria is E.Coli?
Gram negative anaerobic, rod-shaped bacteria
166
What is the triad of pylonephritis?
Fever
Loin pain/back pain
Nausea and vomiting
167
What are differentials to pyelonephritis if not responding to treatment?
Renal abscess
Kidney stone
168
Which investigation is used to look at scarring in the kidneys?
DMSA scan (dimercaptosuccinic acid)
169
What is the community treatment of pyelonephritis?
Cefalexin
Co-amoxiclav
Trimethoprim
Ciprofloxacin
170
How do you calculate serum osmolality?
2(sodium + potassium) + glucose + urea
171
What is the risk with correctly sodium too quickly?
Central pontine myelinolysis
172
How does ADH increase water reabsorption?
Recruits more aquaporin 2 channels to the collecting duct
173
What is a drug used to treat SIADH?
Demelocycline
174
What are the histological findings of IgA nephropathy?
IgA deposits
Mesangial proliferation
C3 deposits
175
What causes acute urinary retention?
UTI
BPH
Alcohol
Medications e.g. anticholinergics, opiate, antidepressants
Pelvic nerve damage
Post anaesthesia
Constipation
176
What should be done after inserting a catheter?
Document residual volume
Take specimen for CSU
Retract foreskin over the penis
177
How much urine is likely to be present in chronic urinary retention?
>1.5L but painless
178
What can occur after treating acute urinary retention?
Post-obstructive diuresis
Monitor hourly urine output and replace losses with IV fluids is needed
179
What causes macroscopic haematuria?
UTI
Renal tract trauma
Renal tract tumour
Renal stone
Schistosomiasis
180
What are risk factors for bladder cancer?
Smoking
Aromatic amines (paint, dye)
Chronic cystitis
Schistosomiasis
181
Where is bladder cancer most likely to spread first?
Local: pelvic structures e.g. uterus, rectum, pelvic side wall
Lymphatic: iliac and paraaoitc lymph nodes
Haeamtogenous: liver, lungs, bone
182
What are the layers from skin to testis?
Skin
Sartos fascia
External spermatic fascia
Cremaster muscle
Internal spermatic fascia (tunica vaginali)
Tunica albuginea
183
What indicates a mass is renal on examination?
Moves up and down with respiration
Palpable on bimanual palpation
Able to get above mass
184
What is the likely renal malignancy in adults?
Renal cell carcinoma
185
What is the likely renal malignancy in children?
Nephroblastoma (Wilm's tumour)
186
Why can Hb be high in renal cell carcinoma?
Increased erythropoietin production
187
What are risk factors for renal cell carcinoma?
Age
Male
Smoking
Obesity
HTN
Long-term dialysis
von Hippel-Lindau
Hereditary papillary RCC
188
What bedside test is useful in kidney stones?
Urinanalysis
189
What is the investigation of choice for renal colic?
CT KUB
190
Why is pain referred to loin to groin in renal colic?
The visceral nerve supply to the ureter and kidneys follows a similar course to the somatic nerve supply to the gonads and flank
191
Why does ureteric obstruction cause pain?
Ureteric spasm arises from peristalsis trying to push the stone through. This causes local ischaemia and hence pain
192
Where are the ureters most narrow and therefore most likely to be obstructed?
Renal pelvis
Pelli-ureteric junction
Vesico-ureteric junction
193
What lifestyle factors can help to reduce renal stones?
Increase water intake
Maintain calcium intake 1-1.2g
Reduce oxalate rich foods
Vitamin C reduction
194
Why does a hydrocele form?
Arises in the tunica vaginalis
Derived from the processes vaginalis which is connected to the embryonic peritoneum
195
Why is a hydrocele plicated?
To ensure it does not reaccumulate
196
How is a hydrocele managed < 1 years old?
Conservative as they most resolve on their own
197
What are specific complications of a TURP?
Clot retention
Bladder neck stenosis
Bladder wall injury
Retrograde ejaculation
Haematospermia
TURP syndrome
198
What is the pathophysiology of TURP syndrome?
Irrigation fluid (glycine) from the operation enters the systemic circulation. It expands the intravascular space, causing a state of fluid overload and hyponatraemia
199
What is the pathophysiology of stress incontinence?
Urine leaks due to raised intra abdominal pressure as the pelvic floor and the pelvic fascia fail to support the urethra so that intra-abdominal and vesicle pressure exceeds that of urethral closure
200
What are risk factors for stress incontinence?
Childbirth
Surgery to pelvic floor
Chronic cough
Obesity
201
What are lifestyle measures for stress incontinence?
Weight loss
Smoking cessation
Avoid alcohol/caffeine
Avoid drinking at night time
Pelvic floor exercises
Vaginal pessaries
202
What are SE of anticholinergics?
Dry mouth
Difficulty urination
Constipation
Blurred vision
Drowsiness and dizziness
Acute closed angle glaucoma
203
What are causes of recurrent UTIs in men?
Bladder outflow obstruction e.g. BPH, urethral stricture, indwelling catheter
Neuropathic bladder
Urinary tract surgery
Immunosuppression
Colovesical fistula
204
What are common UTI organisms?
E.Coli
Staph saprophyticus
Klebsiella
Enterococcus
Proteus sp
205
What are causes of a urethral stricture?
Pelvic trauma
Gonorrhoea/chlamydia
Insertion of foreign bodies
Perineal trauma
Urethral instrumentation
Long term catheter
Lichen sclerosus
206
What are complications of a urethral stricture?
Calculus formation in the urinary tract
Chronic infection and spread to cause prostatitis
Epididymitis
Fournier's gangrene
Renal impairment due to obstruction
Bladder diverticular
207
What causes bladder diverticula?
Chronic increase in intravesical pressure causing bladder mucosa to push through the muscle layer. They can become chronically colonised with bacteria
208
What are the subtypes of renal cell carcinoma?
Clear cell (80%)
Papillary (15%)
Chromophobe (5%)
209
What is the classic triad for renal cell carcinoma?
Haematuria
Flank pain
Palpable mass
210
Where does renal cell carcinoma tend to spread?
Renal cell carcinoma tends to spread to the tissues around the kidney, within Gerota’s fascia. It often spreads to the renal vein, then to the inferior vena cava.
211
What are classic metastatic signs of renal cell carcinoma?
Cannonball metastases in the lungs
Can also appear with choriocarcinoma
212
What are the paraneoplastic syndromes associated with renal cell carcinoma?
Polycythaemia: due to secretion of unregulated erythropoietin
Hypercalcaemia: due to secretion of a hormone that mimics the action of parathyroid hormone
Hypertension: due to various factors, including increased renin secretion, polycythaemia and physical compression
Stauffer’s syndrome: abnormal liver function tests (raised ALT, AST, ALP and bilirubin) without liver metastasis
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What are the surgical options for renal cell carcinoma?
Partial nephrectomy (removing part of the kidney)
Radical nephrectomy (removing the entire kidney plus the surrounding tissue, lymph nodes and possibly the adrenal gland)
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What are the non-surgical options for renal cell carcinoma?
Arterial embolisation: cutting off the blood supply to the affected kidney
Percutaneous cryotherapy: injecting liquid nitrogen to freeze and kill the tumour cells
Radiofrequency ablation: putting a needle in the tumour and using an electrical current to kill the tumour cells
Chemotherapy and radiotherapy.
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What are the most common type of kidney stone?
Calcium based:
Calcium oxalate (most common)
Calcium phosphate
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What are the types of kidney stone?
Calcium oxalate
Calcium phosphate
Uric acid
Struvite
Cystine
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What is a stag horn calculus?
Where the stone forms in the shape of the renal pelvis, giving it a similar appearance to the antlers of a deer stag. The body sits in the renal pelvis with horns extending into the renal calyces. They may be seen on plain x-ray films.
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What produces struvite?
Bacteria so struvite stones are associated with infection
The bacteria hydrolyse the urea to ammonia, creating the solid struvite
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What are the investigations for kidney stones?
Urine dipstick: haematuria
Blood tests: U&Es, calcium, infection
Abdominal X-ray: can show calcium stones but not uric acid stones
Non-contrast CT KUB: within 24 hours
Ultrasound KUB: less preferred to CT
Analysis of stone
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How are kidney stones managed?
NAIDS: IM diclofenac, IV paracetamol if NSAID not suitable
Antiemetics: metoclopramide, prochlorperazine, cyclizine
Antibiotics if infection present
Watchful waiting if <5mm
Tamsulosin to aid spontaneous passage of stones
Surgical intervention if >10mm, not passing spontaneously, complete obstruction or infection.
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What are surgical interventions for kidney stones?
Extracorpeal shock wave lithotripsy
Ureterosopy and laser lithotripsy
Percutaneous nephrolithotomy
Open surgery
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How can you reduce the risk of recurrent kidney stones?
Increase oral fluid intake (2.5 – 3 litres per day)
Add fresh lemon juice to water (citric acid binds to urinary calcium reducing the formation of stones)
Avoid carbonated drinks (cola drinks contain phosphoric acid, which promotes calcium oxalate formation)
Reduce dietary salt intake (less than 6g per day)
Maintain a normal calcium intake (low dietary calcium might increase the risk of kidney stones)
Limit dietary protein.
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How do you reduce the risk of calcium stones?
Reduce the intake of oxalate-rich foods (e.g. spinach, beetroot, nuts, rhubarb and black tea)
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How do you reduce the risk of uric acid stones?
Reduce the intake of purine-rich foods (e.g. kidney, liver, anchovies, sardines and spinach)
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What medications can be used in patients with calcium oxalate stones and raised calcium to reduce the risk of recurrence?
Potassium citrate
Thiazide diuretics (e.g. indapamide)
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What is the inheritance of PKD?
Autosomal dominant:
PKD1 gene on chromosome 16
PKD2 gene on chromosome 4.
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What are the extra-renal manifestations of PKD?
Cerebral aneurysms (berry)
Mitral valve prolapse/MR
Hepatic, splenic, pancreatic, ovarian and prostatic cysts
Colonic diverticula
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What are features of PKD?
HTN
Recurrent UTI
Haematuria
Renal stones
Renal impairment
Flank pain
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What is diagnostic for PKD?
US and genetic testing
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How is autosomal recessive PKD usually picked up?
Oligohydramnios on antenatal scans
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What is the management of PKD?
Tolvaptan: can slow the development of cysts and the progression of renal failure
Antihypertensives
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What class of drug is tolvaptan?
Vasopressin receptor antagonist
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Why should contact sport be avoided in PKD?
Risk of cyst rupture
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What medications should be avoided in PKD?
NSAIDs
Anticoagulants
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What does PKD lead to?
Renal failure (end stage by 50)
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What is a normal potassium?
3.5-5.3
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What causes hyperkalaemia?
AKI
CKD
Rhabdomyolysis
ACE inhibitors
Aldosterone antagonists
ARB
NSAIDs
Haemolysis of blood sample can falsely raise
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How much calcium gluconate is given in hyperkalaemia?
10ml of 10%
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Does IV calcium gluconate have any effect on potassium?
No
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Alternative options for hyperkalaemia?
Nebulised salbuatmol
Oral calcium resonium
Sodium bicarbonate
Haemodialysis if persistent
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What does muscle cell death release?
Myoglobulin
Potassium
Phosphate
CK
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What is the management of rhabdomyolysis?
IV fluids
Treat hyperkalaemia
IV sodium bicarbonate to increase urinary pH and reduce the toxic effects of myoglobulinuria
IV mannitol to increase urine output and rescued oedema
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What are the complications of rhabdomyolysis?
AKI
Hyperkalaemia can cause cardiac arrest and cardiac arrhythmias
Compartment syndrome
DIC
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What is haemolytic uraemic syndrome?
Thrombosis in small blood vessels throughout the body
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What triggers haemolytic uraemic syndrome?
Shiga toxins from either E.Coli O157 or Shigella
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How does haemolytic uraemic syndrome lead to AKI?
Formation of blood clots consumes platelets, leading to thrombocytopenia. The blood flow through the kidney is affected by thrombi and damaged RBC, leading to AKI
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Who does haemolytic uraemia syndrome most commonly affect?
Children after an episode of gastroenteritis
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When does haemolytic uraemic syndrome present post gastroenteritis?
Diarrhoea presents first with gastroenteritis
Turns bloody in 3 days
Around a week later, features present:
Fever
Abdominal pain
Lethargy
Pallor
Oliguria
Haematuria
HTN
Bruising
Jaundice
Confusion
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What is the triad for haemolytic uraemic syndrome?
Microangiopathic haemolytic anaemia
AKI
Thrombocytopenia
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What investigation is required for haemolytic uraemic syndrome?
Stool culture for causative organism
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What is type 1 renal tubular acidosis?
Distal tubule cannot excrete hydrogen ions
High urinary pH and hypokalaemia
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What is type 2 renal tubular acidosis?
Proximal tubule cannot reabsorb bicarbonate
High urinary pH and hypokalaemia
253
What is type 3 renal tubular acidosis?
Combination of type 1 and type 2 with pathology in the distal and proximal tubules
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What is type 4 renal tubular acidosis?
Low aldosterone or impaired aldosterone function
Low urinary pH and hyperkalaemia
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Which type of renal tubular acidosis is most common?
Type 4
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Why does nephrotic syndrome occur?
Basement membrane in the glomerulus becomes highly permeable, resulting in significant proteinuria.
257
What is the pathophysiology of minimal change disease?
Damage to the podocytes
258
What is the most common cause of nephrotic syndrome in adults?
Membranous nephropathy
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What are the causes of nephrotic syndrome?
Membranous nephropathy
Focal segmental glomuerlosclerosis (HIV/blood-borne)
Membranoproliferative glomerulonephritis
Henoch-Schonlein purpura
Diabetic nephropathy
Infection e.g. HIV
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What is the urine like in nephrotic syndrome?
Frothy due to protein content
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What is the triad of nephrotic syndrome?
Protein >3g/24 hours
Hypoalbuminaemia <30g/L
Peripheral oedema.
Remember hypercholesterolaemia and hypercoaguable state
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What does nephrotic syndrome increase the risk of?
Venous thrombosis (renal vein thrombosis) due to loss of antithrombin III in urine
263
What is the management of nephrotic syndrome?
Oedema: loop diuretic, restrict salt diet
Proteinuria: ACE-i and ARB
Hyperlipidaemia: statin
Hypercoagulopathy: treatment dose LWMH, warfarin (can't use DOAC)
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What is the triad for nephritic syndrome?
Haematuria (casts)
Oliguria
Hypertension
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What are the signs of nephritic syndrome?
Haematuria: microscopic or macroscopic
Oliguria
Proteinuria: <3g/24hours (if > then suggests nephrotic syndrome)
Fluid retention
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What is the first part of the nephron?
The glomerulus
267
What is the role of the glomerulus?
Filters out the capillaries and into the renal tubule
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What are the types of glomerulonephritis?
IgA nephropathy (Berger's disease)
Membranous nephropathy
Membranoproliferative glomerulonephritis
Post-streptococcal glomerulonephritis
Goodpasture syndrome (anti-glomerular basement membrane disease)
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How do you differentiate between IgA nephropathy and post-strep glomerulonephritis?
IgA will be shorter onset than post-strep (post-strep presents 1-3 weeks after the strep infection)
Main symptoms of post-strep is proteinuria but haeamaturia can occur
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What is the most common cause of primary glomerulonephritis?
IgA nephropathy
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What is the typical presentation of IgA nephropathy?
20 year old presenting with haematuria
272
What is low in post-strep glomerulonephritis?
Complement levels
273
What is shown on histology of membranous nephropathy?
IgG
Complement deposits on the basement membrane
274
What causes membranous nephropathy?
Mostly idiopathic (70%)
Can be secondary to malignancy, SLE or drugs e.g. NSAIDs
275
What is the pathophysiology of membranous nephropathy?
Deposits of immune complexes in the glomerular basement membrane, causing thickening and malfunctioning of the membrane and proteinuria
276
What does histology show in rapidly progressive glomerulonephritis (aka crescentic glomerulonephritis)?
Glomerular crescents
277
What is the pathophysiology of Goodpasture's syndrome?
Anti-glomerular basement membrane antibodies attack the glomerulus and pulmonary basement membranes causing glomerulonephritis and pulmonary haemorrhage
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What is the typical presentation of Goodpasture's syndrome?
Patient in their 20s or 60s presenting with acute kidney failure and haemoptysis
279
Which systemic diseases can cause glomerulonephritis?
Henoch-Schonlein Purpura
Vasculitis e.g. microscopic polyangitis, Wegener's (granulomatosis with polyangitis)
Lupus nephritis (associated with SLE)
280
Which antibodies are associated with microscopic polyangitis?
p-ANCA or MPO
281
Which antibodies are associated with granulomatosis with polyangitis?
c-ANCA or PR3
282
What is diagnostic for glomerulonephritis?
Renal biopsy
283
What is the treatment for glomerulonephritis?
Supportive care e.g. antihypertensives, dialysis
Immunosuppression e.g. corticosteroids
284
What are complications linked to immunosuppression in renal transplant?
IHD
T2DM (steroids)
Infections more likely e.g. PCP, MCV, TB
Non-Hodkin lymphoma
Skin cancer (particularly SCC)
285
What immunosuppressants are used in renal transplant?
Acute rejection: Basiliximab (monoclonal antibody targeting interleukin 2 receptor on T cells). Two doses given after surgery to prevent acute rejection
Tacrolimus
Mycophenolate
Ciclosporin
Azathioprine
Prednisolone
286
What is a side effect of long term steroid use?
Features of Cushing's
287
What are signs on examination of a renal transplant?
Hockey-stick scar
Palpable in the iliac fossa
288
How are renal transplants matched to the patient?
HLA type A, B and C on chromosome 6
289
Which vessels are used to anastomose the donor kidney to the bladder?
External iliac vessels
290
Which dialysis is good for acute?
CRRT
291
What are the indications for short-term dialysis?
A acidosis pH<7.2
E electrolyte abnormalities especially refractory hyperkalaemia
I ntoxication (overdose e.g. lithium, salicylates)
O edema severe and unresponsive pulmonary oedema
U raemia encephalopathy or pericarditis
292
What are the options for dialysis?
Haemolysis
Peritoneal dialysis
293
What are SE of haemolysis dialysis?
Hypotension and cardiac arrests due to large volume taken
294
What can be used for long term access in haeolysis dialysis?
Arteriovenous fistula (bypasses capillary system so high pressure arterial blood flow, requires a surgical operation to create and a maturation period of 4-16 weeks e.g. radiocephalic, brachiocephalic, brachiobasilic. STEAL syndrome when there becomes inadequate flow to the limb where the fistula is)
Tunnelled cuffed catheter (tube into subclavian or jugular vein with tip in the SVC or RA with two lumens)
295
What catheter is used in peritoneal dialysis?
Tenckhoff catheter
296
What do blood show in renal bone disease?
High serum phosphate
Low Vitamin D
Low serum calcium
297
Why is calcium low in CKD?
Less activation of Vitamin D in the kidney and so less reabsorption of calcium
298
Why does osteomalacia occur?
Increased turnover of bones without adequate blood supply
Osteosclerosis then occurs when the osteoblasts respond by increasing their activity to match the osteoclasts creating new tissue in the bone
299
What are causes of CKD?
Age
Diabetes
HTN
Medications
Glomerulonephritis
PKD
300
What is the target BP in CKD?
130/80
301
What is the diagnosis of CKD?
eGFR < 60ml OR
Urine albumin:creatinine (ACR) >3 sustained
302
How is CKD investigated?
eGFR
Urine ACR: proteinuria
Urine dipstick or microscopy
Renal US
303
What is accelerated progression of CKD?
Sustained decline in eGFR within one year of either 25% or 15ml
304
How is the ACR classified?
A1 = <3mg/mmol
A2 = 3-30
A3 = >30
305
What is used to determine the risk of CKD causing kidney failure requiring dialysis in the next 5 years?
Kidney Failure Risk Equation
306
When do you refer CKD to a specialist?
eGFR < 30
Urine ACR >70
Accelerated progression
5 year risk score > 5%
Uncontrolled HTN despite 4 or more antihypertensives
307
What medications slow disease progression in CKD?
ACE-inhibitor or ARB when:
Diabetes + ACR >3
HTN + ACR >30
All patients ACR >70
SGLT2 inhibitors when urine ACR >30
308
What are the complications of CKD?
Metabolic acidosis: treat with oral sodium bicarbonate
Anaemia: treat with iron and recombinant erythropoietin (normocytic normochromic anaemia)
Renal bone disease: treat with Vitamin D and low phosphate diet/phosphate binder
CVD
Peripheral neuropathy
End stage kidney disease
Dialysis complications
309
What is acute tubular necrosis?
Damage and death of the epithelial cells of the renal tubules
310
What causes renal tubular acidosis?
Ischaemia due to hypo perfusion (haemorrhage common)
Nephrotoxins e.g. gentamicin, radiocontrast agents, cisplatin
311
What is the most common intrinsic cause of AKI?
Acute tubular necrosis
312
What is diagnostic for acute tubular necrosis?
Muddy brown closets on urinalysis
Renal tubular epithelial cells may also be seen
313
What will the response to a fluid challenge be in acute tubular necrosis?
Poor
314
What is the serum urea:creatinine ratio in pre-renal AKI compared to acute tubular necrosis?
Raised in pre-renal AKI
Normal in acute tubular necrosis
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