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Phase 2a > Urology > Flashcards

Urology Flashcards

1
Q

What are the 3 functions of the urinary tract

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

What type of organ is the kidney

A

Retroperitoneal

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3
Q

Where does the kidney lie

A

T11-L3

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4
Q

Where does the blood supply to the kidney come from

A

Renal artery direct from aorta at L1 level

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5
Q

How much urine is produced per day

A

1-1.5L

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6
Q

What type of structure are the ureters

A

Retroperitoneal

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7
Q

Where do the ureters run

A

Over psoas muscle, cross the iliac vessel at the pelvic brin and insert into trigone of bladder

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8
Q

How long are the ureters

A

25-30cm

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9
Q

How is reflux of urine prevented

A

By valvular mechanism at the vesicoureteric junction

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10
Q

Where are the 3 anatomical narrowings of the ureters

A

Pelvic ureteric junction
Crosses iliac vessels
Crosses into the back of the bladder - trigone

Kidney stones can get stuck

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11
Q

Name the 4 nerve supply to the bladder and sphincter

A

Parasympathetic nerve
Sympathetic nerve
Somatic nerve
Afferent pelvic nerve

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12
Q

Describe the nerve supply to the bladder by the parasympathetic nerve

A

Pelvic nerve

S2-4 - S2,3,4 keeps the pee of the floor

Acetylcholine neurotransmitter

Involuntary control

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13
Q

Describe nerve supply to the bladder and sphincter by the sympathetic nerve

A

Hypogastric nerve

T11-L2

Noradrenaline neurotransmitter

Involuntary control

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14
Q

Describe the nerve supply to the bladder and sphincter by the somatic nerve

A

Pudendal nerve

S2-4

‘Onuf’s nucleus’

Acetylcholine neurotransmitter

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15
Q

Describe the nerve supply to the bladder and sphincter by the afferent pelvic nerve

A

Sensory nerve

Signal from detrusor muscle

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16
Q

Describe the neural control of the bladder

A

Cortex = voluntary control

Pontine micturition centre/periaqueductal grey = co-ordination of voiding

Sacral micturition centre = micturition reflex

Onuf’s nucleus = guarding reflex

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17
Q

Describe the micturition of the bladder

A

98% = storage phase

Either to:

Guarding phase = inappropriate to void

Micturition phase = appropriate to void

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18
Q

Describe the storage phase of the bladder

A

Bladder fills continuously
- capacity 400-500mL
- first sensation 100-200mL

Volume bladder increases - pressure remains low due to ‘receptive relaxation’ and detrusor muscle compliance

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19
Q

Describe the filling phase of the bladder

A

Lower volumes the afferent pelvic nerve sends slow firing signals to the pons via the spinal cord

Sympathetic nerve stimulation = maintains the detrusor muscle relaxation

Somatic nerve stimulation = maintains ureteral contraction

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20
Q

Describe the voiding phase of the bladder (micturition reflex)

A

= Autonomic spinal reflex

Higher volumes stimulate afferent pelvic nerve to send fast signals to the sacral micturition centre in the sacral spinal cord.

Pelvic parasympathetic nerve stimulated = detrusor muscle contracts.

Pudendal nerve inhibited = external sphincter relaxes

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21
Q

Describe bladder emptying

A

Detrusor contraction + external sphincter relaxation

Positive feedback until all urine expelled.

After complete detrusor relaxation and external sphincter contraction

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22
Q

Describe the guarding reflex of the bladder

A

Adults have voluntary control of bladder.

Afferent signals from pelvic nerve received by PMC/PAG and transmitted to higher cortical areas.

If voiding inappropriate - guarding reflex occurs.

Sympathetic nerve stimulation = detrusor relaxation

Pudendal nerve stimulation = external urethral sphincter.

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23
Q

Describe storage of the bladder

A

Receptive relaxation

Detrusor relaxation - sympathetic stimulation T11-L2

External uretheral sphincter contraction - pudendal stimulation S2-4

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24
Q

Describe the nerve supply of micturition

A

Voluntary control from cortex and PMC

Detrusor contraction - parasympathetic stimulation S2-4

External urethral sphincter relaxation - pudendal inhibition S2-4

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25
Q

Define acute kidney injury

A

Acute decline in kidney function, leading to a rise in serum creatinine and/or fall in urine output.

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26
Q

Describe the 3 main types of causes of acute kidney injury

A

Pre-renal (most common)
Renal
Post-renal

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27
Q

Describe pre-renal acute kidney injury

A

Insufficient blood supply (hypoperfusion) to the kidneys reduces the filtration of blood

Dehydration
Shock
Heart failure

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28
Q

What is the most common cause of acute kidney injury

A

Pre-renal

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29
Q

Describe renal acute kidney injury

A

Intrinsic disease in the kidney

Example - acute tubular necrosis (most common form)

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30
Q

Describe post-renal acute kidney injury

A

Obstruction to the outflow of urine away from the kidney, causing back pressure into the kidney and reduces kidney function = obstructive uropathy

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31
Q

Name examples that could cause renal acute kidney injury

A

Acute tubular necrosis

Glomerulonephritis

Acute interstitial nephritis

Haemolytic uraemic syndrome

Rhabdomyolysis

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32
Q

Name examples of post-renal acute kidney injury

A

Kidney stones

Tumours - retroperitoneal, bladder or prostate.

Strictures of the ureters or urethra

Benign prostatic hyperplasia

Neurogenic bladder

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33
Q

Describe the risk factors of acute kidney injury

A

Older age (above 65)
Sepsis
Chronic kidney disease
Heart failure
Diabetes
Liver disease
Cognitive impairment
Medications

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34
Q

Name 3 clinical features of acute kidney injury

A

Hypotension
Reduced urine production
Lower UTI symptoms

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35
Q

Describe the investigations for acute kidney injury

A

Urinalysis - assess for protein, blood, leucocytes, nitrates and glucose.

Ultrasound

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36
Q

Describe the NICE guidelines for the diagnosis of an AKI

A

Rise in creatinine of more than 25 micromol/L in 48 hours

Rise in creatinine of more than 50% in 7 days

Urine output of less than 0.5 ml/kg/hour over at least 6 hours

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37
Q

Describe the management of acute kidney injury

A

Treatment - reverse underlying cause and supportive management

IV fluids
Without medications
Withhold/adjust medications
Relieve obstruction in a post-renal AKI
Dialysis may be required in severe cases

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38
Q

Describe the prevention of acute kidney injury

A

Avoid nephrotoxic medications where appropriate

Ensuring adequate fluid intake

Additional fluids before and after radiocontrast

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39
Q

What are the differential diagnosis of acute kidney injury

A

Chronic kidney disease
Increased muscle mass
Drug side effects

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40
Q

Define chronic kidney disease

A

Chronic reduction in kidney function sustained over three months - tends to be permanent and progressive

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41
Q

Describe the aetiology of chronic kidney disease

A

Naturally declines with age

Factors that speed up decline
- diabetes
- hypertension
- medications
- glomerulonephritis
- polycystic kidney disease

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42
Q

Define the risk factors of chronic kidney disease

A

Diabetes mellitus
Hypertension
Age > 50 years
Childhood kidney disease

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43
Q

Describe the clinical features of chronic kidney disease

A

Most asymptomatic

Signs and symptoms
Fatigue
Pallor
Foamy urine
Nausea
Loss of appetite
Pruritus
Oedema
Hypertension
Peripheral neuropathy

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44
Q

Describe the investigations for chronic kidney disease

A

eGFR
Proteinuria
Haematuria
Renal ultrasound

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45
Q

How is chronic kidney disease diagnosed

A

eGFR - below 60ml/min/1.73^2 - G score

ACR (quantified with urine albumin: creatinine ration) - above 3 mg/mmol - A score

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46
Q

What are the two scoring systems which can be used in chronic kidney disease

A

G score

A score

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47
Q

In chronic kidney disease what is used to estimate 5-year risk of kidney failure requiring dialysis

A

Kidney failure risk equation

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48
Q

Describe the management of chronic kidney disease

A

Treating underlying case

Reduce risk of complications

Management of end-stage renal disease

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49
Q

What medications can be used to help slow disease progression in chronic kidney disease

A

ACE inhibitors

SLGT-2 inhibitors

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50
Q

Define erectile dysfunction

A

Inability to achieve or maintain an erection sufficient for sexual performance

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51
Q

Describe the physiology of an erection

A

Autonomic

Somatic

Central

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52
Q

Describe the autonomic control of the physiology of an erection

A

Parasympathetic S2-4 produce erection

Sympathetic T11-L2 ejaculation and detumescence

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53
Q

Describe the somatic control of the physiology of an erection

A

Afferent dorsal penile to pudendal to S2-4

Efferent Onus’s nucleus to ischiocavernosus and bulbocavernosus

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54
Q

Name the causes of erectile dysfunction

A

IMPOTENCE

Inflammatory
Mechanical
Psychological
Occlusive (Vascular)
Trauma
Extra
Neurogenic
Chemical
Endocrine

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55
Q

Name the risk factors of erectile dysfunction

A

Arterial disease
Psychosexual/relationship problems
Excess alcohol intake
Diabetes
Smoking

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56
Q

Describe the clinical features of erectile dysfunction

A

History

No clinical signs

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57
Q

Describe the essential tests of erectile dysfunction

A

Blood pressure

Essential bloods
- fating glucose and lipids
- early morning testosterone

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58
Q

Describe the 1st line management of erectile dysfunction

A

PDE5 inhibitors

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59
Q

Describe the 2nd line management of erectile dysfunction

A

Alprostadil

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60
Q

Describe the 3rd line management of erectile dysfunction

A

Devices - pumps blood into the penis

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61
Q

Describe prostate cancer

A

Almost always androgen dependent

Majority = adenocarcinomas.

Grown in peripheral zone of the prostate

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62
Q

Name the risk factors of prostate cancer

A

Increasing age

Family history

Black African or Caribbean origin

Tall stature

Anabolic steroids

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63
Q

Describe the cause of prostate cancer

A

Unknown

Possible
High fat diet
Genetic factors
Ethnicity
Hormonal influence

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64
Q

Describe the clinical features of prostate cancer

A

May be asymptomatic

Symptomatic - lower urinary tract symptoms

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65
Q

Describe the investigations for prostate cancer

A

Prostate examination

Multiparametric MRI
Prostate biopsy
Isotope bone scan

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66
Q

Describe the feeling of a benign prostate on a prostate examination

A

Smooth, symmetrical and slightly soft

Maintained central sulcus

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67
Q

Describe the feeling of prostatitis (infected or inflamed prostate) on a prostate examination

A

Enlarged, tender and warm

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68
Q

Describe the feeling of a cancerous prostate on a prostate examination

A

Firm or hard, asymmetrical, craggy or irregular

Loss of central sulcus

May be hard nodule

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69
Q

What is the first line investigation in the diagnosis of prostate cancer

A

Multiparametric MRI

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70
Q

Describe a multiparametric MRI in prostate cancer

A

Results are scaled

1- very low suspicion to 5 - definite cancer

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71
Q

What grading system is used in prostate cancer

A

Gleason Grading

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72
Q

Describe the Gleason Grading system

A

Based on histology

Determines what treatment is appropriate

Grade 1 (closest to normal) to 5 (most abnormal)

Made up of 2 scores - the two most prevalent patterns in biopsy

6 = low risk
7 = intermediate
8 = high risk

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73
Q

Describe TNM Staging

A

T = tumour

N = nodes

M = metastasis

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74
Q

Describe the management of prostate cancer

A

Early = surveillance or watchful waiting

External beam radiotherapy

Brachytherapy

Hormone therapy

Surgery

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75
Q

Name 2 differential diagnosis of prostate cancer

A

Benign prostatic hyperplasia

Chronic prostatitis

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76
Q

Where does advanced prostate cancer spread to

A

Lymph nodes and bone

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77
Q

Describe the pathophysiology of testicular cancer

A

Arises from the germ cells of the testes

Germ cells produce gametes

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78
Q

What are the two types of testicular cancer

A

Seminomas
Non-seminomas

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79
Q

Describe the metastasis of testicular cancer

A

Lymphatic spread

Often occurs through spermatic cord lymphatics to the retroperitoneal lymph node chain

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80
Q

Describe the causes of testicular cancer

A

Genomic alterations

Congenital abnormalities

Perinatal factors

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81
Q

Name the risk factors of testicular cancer

A

Undescended testes

Male infertility

Family history

Increased height

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82
Q

Describe the typical presentation of testicular cancer

A

Painless lump

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83
Q

Describe the lump of testicular cancer

A

Non-tender
Arising from testicle
Hard
Irregular
Not fluctuant
No transillumination

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84
Q

Describe the investigations for testicular cancer

A

1st - scrotal ultrasound - confirm diagnoses

Tumour markers

Staging CT scan

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85
Q

What staging system is used in testicular cancer

A

Royal Marsden Staging System

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86
Q

Describe the Royal Marsden Staging System

A

Stage 1 - isolated

Stage 2 - spread to lymph

Stage 3 - spread above the diaphragm

Stage 4 - metastases to other organs

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87
Q

What are the common places that testicular cancer may metastasise

A

Lymphatics
Lungs
Liver
Brain

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88
Q

Are biopsies used in testicular cancer

A

Not advised

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89
Q

Describe the management of testicular cancer

A

Surgery - remove affected testicle

Chemotherapy
Radiotherapy

Sperm banking

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90
Q

Define bladder cancer

A

Arises from the endothelial lining (urothelium).

Majority are superficial (not invading the muscle) at presentation

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91
Q

Describe the pathophysiology of bladder cancer with carcinogens

A

Carcinogens are concentrated and excreted in urine - exposes to wall of urinary tract.

Exposure is prolonged to the bladder - malignant transformation can arise anywhere in the urinary tract

Malignant transformation of urothelial cells - high amount of mutations

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92
Q

Name 3 causes of bladder cancer

A

Smoking - main

Occupational risk to chemical carcinogens

Family history

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93
Q

Name the 2 main risk factors of bladder cancer

A

Smoking

Increased age

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94
Q

Name the clinical feature of bladder cancer

A

Painless haematuria

  • Visible haematuria
  • Microscopic haematuria
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95
Q

Describe the investigations of bladder cancer

A

Urinalysis

Cystoscopy

Bloods - FBC

Further imaging

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96
Q

Name the two types of bladder cancer

A

Non-muscle invasive bladder cancer

Muscle-invasive bladder cancer

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97
Q

Name 4 risk factors of bladder cancer

A

Smoking
Increased age

Aromatic amines - carcinogens
Schistosomiasis

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98
Q

Describe the NICE guidelines for a 2-week referral for bladder cancer

A

> 45 + unexplained visible haematuria

> 60 + microscopic haematuria + dysuria (or) raised with blood cell FBC

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99
Q

Describe the management options of bladder cancer

A

Transurethral resection of bladder tumour

Intravesical chemotherapy

Intravesical Bacillus Calmette-Guerin

Radical cystectomy

Chemotherapy/radiotherapy

Muscle-invasive tumours

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100
Q

Name the differential diagnosis for bladder cancer

A

Benign prostatic hyperplasia
Haemorrhagic cystitis
Prostatitis
UTI

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101
Q

Define benign prostate hyperplasia

A

Hyperplasia of the stromal and epithelial cells of the prostate

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102
Q

Describe the pathophysiology of benign prostate hyperplasia

A

LUTS caused by bladder outlet obstruction

2 components

Static - increase in tissue narrowing the urethral lumen

Dynamic - increase in muscle tone mediated by alpha-adrenergic receptors

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103
Q

Describe the causes of benign prostate hyperplasia

A

Shift in age related hormones

Prostatic stromal-epithelial interactions can occur with ageing

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104
Q

Name the risk factors of benign prostate hyperplasia

A

Age > 50
Family history
Non-Asian race
Cigarette smoking
Male pattern baldness
Metabolic syndrome

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105
Q

Name the clinical feature of benign prostate hyperplasia

A

LUTs

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106
Q

Describe the management of benign prostate hyperplasia

A

Mild symptoms - may not require interventions

Medications

Alpha-blockers
5-alpha reductase inhibitors

Surgical treatments

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107
Q

Name the differential diagnosis of benign prostate hyperplasia

A

Overactive bladder
Prostatitis
Prostate cancer
UTIs
Bladder cancer
Neurogenic bladder

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108
Q

Define hydrocele

A

Collection of fluid within the tunica vaginalis that surrounds the testes

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109
Q

Name the cause of hydrocele

A

Can be idiopathic

Or secondary
- testicular cancer
- testicular torsion
- Epididymo-orchitis
- Trauma

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110
Q

Name the risk factors of hydrocele

A

Male sex
Prematurity and low birth weight
Infants < 6 months of age
Infants whose testes descend relatively late

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111
Q

Name the clinical features of hydrocele

A

Painless
Soft scrotal swelling

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112
Q

Name the examination findings in hydrocele

A

Testicle palpable within the hydrocele

Soft, fluctuant - may be large

Irreducible and has no bowel sounds

Transilluminated

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113
Q

Name the investigations of hydrocele

A

Clinical diagnosis

Ultrasound - check for underlying pathology

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114
Q

Name the management of hydrocele

A

Exclude serious causes

Idiopathic hydroceles - managed conservatively

Large/symptomatic cases - surgery, aspiration or sclerotherapy

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115
Q

Define varicocele

A

Occurs where the veins in the pampiniform plexus become swollen

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116
Q

Describe the pathophysiology varicocele

A

Most occur left due to increased resistance of the left testicular vein (drains into the left renal artery)

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117
Q

Name the causes of varicocele

A

Anatomical features

Increased hydrostatic pressure in left renal vein

Incompetent or congenitally absent valves

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118
Q

Name the risk factors of varicocele

A

Somatometric parameters - tall/low BMI

Family history

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119
Q

Describe the symptoms of varicocele

A

Throbbing/dull pain or discomfort, worse when standing

Dragging sensation

Sub-fertility or infertility

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120
Q

Describe the signs of varicocele

A

Scrotal mass

More prominent on standing

Disappears when lying down

Asymmetry in testicular size if the varicocele has affected growth of the testicle

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121
Q

When would a suspected varicocele be a concern

A

If it does not disappear when lying down

Concerns about retroperitoneal tumours

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122
Q

How are varicocele diagnosed

A

Clinical

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123
Q

Describe the management of varicocele

A

Uncomplicated - conservative management

Pain, testicular atrophy or infertility - surgery or endovascular embolism may be indicated

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124
Q

Describe the pathology of penile cancer

A

95% are squamous cell carcinoma

3% Kaposi sarcoma

Precursor lesions
- HPV dependent undifferentiated PEIN
- HPV independent differentiated PEIN

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125
Q

Describe the epidemiology of penile cancer

A

Rare
1% male cancers
Incidence is increasing

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126
Q

What is the main cause of penile cancer

A

HPV

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127
Q

Name the risk factors of penile cancer

A

Increasing age
Premalignant lesions
Phimosis
Geography
HPV
Smoking
Immunocompromised
PUVA therapy

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128
Q

Describe the clinical features of penile cancer

A

Hard painless lump
Gland or prepuce
Up to 50% delay presenting
Blood discharge - haematuria

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129
Q

Describe the examination findings of a patient

A

General appearance and fitness
Abdomen
Lymph nodes in groins
Penis, lesion itself
DRE

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130
Q

Describe the investigations of penile cancer

A

Examination
Biopsy
Imaging - MRI for local staging, ultrasound
CT chest, abdomen and pelvis

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131
Q

Describe the management of superficial penile

A

Cream

Glands re-surfacing - take skin of the thigh

Get biopsy - can give local staging

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132
Q

Describe the management for invasive penile cancer

A

Removal
- Glandectomy
- Partial penectomy
- Radical penectomy

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133
Q

Describe the treatment for metastatic disease of penile cancer

A

Palliative surgery

Platinum chemotherapy

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134
Q

What are the differential diagnosis for penile cancer

A

Infections
- herpes simplex
- syphilis

Inflammatory conditions
- psoriasis
- lichen planus
- balanitis

Premalignant conditions
- genital warts
- Bowens disease
- Lichen sclerosus

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135
Q

Define hydrocele

A

Collection of fluid within the vaginalis that surrounds the testes

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136
Q

Define polycystic kidney disease

A

Genetic condition where the healthy kidney tissue is replaced by many fluid-filled cysts

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137
Q

What are the two types of polycystic kidney disease

A

Autosomal dominant
Autosomal recessive

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138
Q

Describe autosomal recessive polycystic kidney disease

A

More severe than autosomal dominant

Mutation in polycystic and hepatic disease (PKHD1) gene on chromosomal 6

Often picked up on antenatal scans with oligohydramnios

End-stage renal failure usually occurs before reaching adulthood.

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139
Q

What type of polycystic kidney disease is most common

A

Autosomal dominant

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140
Q

Describe autosomal dominant polycystic kidney disease

A

PKD1 gene on chromosome 16 - 85% cases

PKD2 gene on chromosome 4 - 15%

Has specific extra renal manifestations and complications

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141
Q

Name the risk factors for polycystic kidney disease

A

Family history of PKD

Family history of cerebrovascular event

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142
Q

Name the characterisations of polycystic kidney disease

A

Renal cysts
Extrarenal cysts
Intracranial aneurysms
Aortic root dilation and aneurysms
Mitral valve prolapse
Abdominal wall hernias

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143
Q

Describe the clinical features of polycystic kidney disease

A

Renal cysts
Hypertension
Abdominal/flank pain
Haematuria
Palpable kidneys/abdominal mass
Headaches
Dysuria, suprapubic pain, fever

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144
Q

Name the extra renal manifestations in autosomal dominant polycystic kidney disease

A

Cerebral aneurysms
Hepatic, splenic, pancreatic, ovarian, and prostatic cysts
Mitral regurgitation
Colonic diverticula

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145
Q

Name the investigations for polycystic kidney disease

A

Ultrasound
Genetic testing

Other tests
- other imaging
- urinalysis/gram stain
- serum electrolytes, urea, creatinine
- Fasting lipid profile
- ECG

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146
Q

Name the management of autosomal dominant polycystic kidney disease

A

Tolvaptan - vasopressin receptor antagonist

Can slow development of cysts and progression to renal failure

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147
Q

Describe the general management of polycystic kidney disease

A

Antihypertensives
Analgesia
Antibiotics
Drainage
Dialysis
Renal transplant

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148
Q

What is the most common cause of chronic kidney disease

A

Diabetes

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149
Q

What tests are used to monitor chronic kidney disease

A

eGFR

Albumin :creatinine ratio (ACR)

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150
Q

Describe the treatment plan for the control of hypertension is chronic kidney disease

A

uACR < 30 = follow NICE HTN guidelines

uACR > 30 = ACE/ARB 1st line

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151
Q

Describe dialysis

A

2 types

Haemodialysis

Peritoneal dialysis

Large impacts to life

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152
Q

Describe haemodialysis

A

Centre or home

Via AV fistula, graft or tunnelled line

3 days per week

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153
Q

Describe peritoneal dialysis

A

Via PD tube in abdominal wall

CAPD 1-4 exchanges per day

APD - 12 hours overnight

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154
Q

Approximately how many nephrons are present in the kidney? (total number over both kidneys)

A

2 million

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155
Q

What is the approximate number of litres of blood filtered by the kidneys per day?

A

180L

Approx. 179L reabsorbed

156
Q

What is GFR influenced by

A

Net filtration pressure (NFP)
- hydrostatic pressure
- colloid osmotic pressures

Renal blood flow
- autoregulation

Filtration coefficient
- arteriolar endothelium (net -ve charge)
- glomerular podocytes

157
Q

What is the biggest contributor to glomerular filtration pressure

A

Glomerular hydrostatic pressure (fluid out)

158
Q

What are the 4 forces which affect the glomerular filtration pressure

A

Out
- Glomerular hydrostatic pressure
- Bowman’s capsule colloid osmotic pressure

In
- Bowman’s capsule fluid pressure
- Glomerular colloid osmotic pressure

159
Q

What is the equation of net filtration pressure

A

GHP - (BCP + pieG)

Glomerular hydrostatic pressure - (bowman’s capsule pressure + glomerular colloid osmotic pressure)

160
Q

What would constriction of the afferent arteriole in the nephron cause?

A

Reduced GFR
Reduce peritubular flow

161
Q

Describe renal autoregulation

A

Intrinsic feedback mechanism

Involves
- afferent and efferent arterioles
- tubuloglomerular feedback

162
Q

What is the equation GFR as an indicator of renal function

A

= (creatinine urine / creatinine plasma) x urine flow rate (ml/min)

163
Q

Name the drawbacks of eGFR

A

Does not consider creatinine tubular secretion (10-15% over estimate)

Creatinine metabolism reflection on lean body mass

Cimetidine, trimethoprim inhibit creatinine secretion.

Not valid in pregnancy

164
Q

Name the drugs which can result in acute kidney injury

A

DAMN

Diuretics
ACEi/ARB
Metformin
NSAIDs

165
Q

Name 6 factors that can reduce GFR

A

NSAIDs - increase afferent artery resistance

Angiotensin II (ACEi/ARB) - decrease efferent artery resistance

Increase plasma proteins (oncotic pressure) - decrease renal blood flow

Reduced arterial pressure - decreased GHP

Urinary tract obstruction (kidney stones) - Increased bowman’s capsule pressure

Renal disease, diabetes mellitus, hypertension - decrease K

166
Q

What ion has a key role in determining plasma volume and osmolality

A

Na+

167
Q

Describe atrial natriuretic peptide effect in the kidneys

A

Afferent arteriole dilation - increase GFR

Inhibits renin secretion
- decrease angiotensin II, aldosterone secretion, systemic vascular resistance.

168
Q

Name 3 inducers of renin secretion

A

Hypotension - decrease in afferent arteriole pressure

Decrease Na - macula densa

Increased sympathetic stimulation (B1) in JG Glandular cells

169
Q

Name 6 roles of angiotensin-II functions

A

Increase SVR (vasoconstriction)

Increase ADH secretion

Induces cardiac hypertrophy

Increase aldosterone secretion

Increase Na+ uptake

Enhances sympathetic adrenergic activity

170
Q

What is the cell of spermatogenesis

A

Sertoli cells

171
Q

What is the cell in the testes with hormone production

A

Leydig cells

172
Q

Describe the descent of the testes

A

8th week - transabdominal decent

26th week - testosterone produced - finish decent into the scrotum

Undescended can end up anywhere - most commonly the inguinal canal

173
Q

Describe chlamydia

A

Intracellular organism - enters and replicates within the cells before rupturing the cell and spreading to others.

Incubation = 7-21 days.

Chlamydia trachomatis

Gram negative bacteria

174
Q

What are the most sexually transmitted disease

A

Chlamydia

175
Q

Name the risk factors for chlamydia and gonorrhoea

A

Age under 25 years

Sexually active

New/multiple partners

Condoms not used

History of prior STI

176
Q

Describe the general clinical feature of chlamydia

A

Asymptomatic

50% men
75% in women

Can still pass on the infection

177
Q

Name 5 symptoms of chlamydia in women

A

Abnormal vaginal discharge

Pelvic pain

Abnormal vaginal bleeding

Painful sex - dyspareunia

Painful urination - dysuria

178
Q

Name 4 symptoms of chlamydia in men

A

Urethral discharge or discomfort

Painful urination - dysuria

Epididymo-orchitis

Reactive arthritis

179
Q

Name the investigations for chlamydia and gonorrhoea

A

Charcoal test - allow for microscopy, culture and sensitivities

Nucleic amplification test - check for DNA or RNA

Examination

180
Q

What do charcoal swabs which allow for microscopy, culture and sensitivities test for

A

Bacterial vaginosis
Candidiasis
Gonorrhoeae
Trichomonas vaginalis
Other bacteria e.g. group B strep

181
Q

Describe the management of chlamydia

A

1st line - doxycycline
Contradicted in pregnancy and breastfeeding

Test of cure - not routinely done

Other management
- contact tracing
- Abstain for sex for 7 days
- treat and test other STIs
- advice

182
Q

Name some examples of complications of chlamydia and gonorrhoea

A

Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Epididymo-orchitis (men)
Prostatitis (men)
Conjunctivitis

183
Q

What is a medical emergency which is a complication of sexually transmitted disease in pregnancy

A

Gonococcal conjunctivitis in a neonate

Infection contracted from the mother during birth = ophthalmia neonatorum

Associated with sepsis, perforation of the eye and blindness.

184
Q

Describe the National Chlamydia Screening Programme

A

Aims to screen every sexually active person under the age of 25 years

Annually or when change sexual partner

Test positive = re-test 3 months after treatment

185
Q

Describe Gonorrhoea

A

Neisseria gonorrhoeae

Gram negative diplococcus bacteria

Infects mucous membranes with columnar epithelium

Spreads via contact with mucous secretions from infected areas.

186
Q

Name the general clinical features of gonorrhoea

A

More likely to be symptomatic than chlamydia

90% of men
50% of women

Odourless purulent discharge - possibly green or yellow

Dysuria

Pelvic pain (females)/testicular pain or swelling - Epididymo-orchitis (males)

187
Q

Name 4 other areas where someone could have a gonorrhoea infection

A

Rectal infection
Pharyngeal infection
Prostatitis
Conjunctivitis

188
Q

Describe the management of gonorrhoea

A

High level antibiotic resistance to ciprofloxacin and azithromycin

Single dose IM ceftriaxone - sensitives NOT known

Single dose oral ciprofloxacin - sensitives known

All patients followed up
- NAAT test = asymptomatic
- Culture = symptomatic

189
Q

Complication of gonorrhoea - disseminated gonococcal infection

A

Complication of untreated gonococcal infection where the bacteria has spread to the skin and joints

Causes
- Non-specific skin lesions
- Polyarthralgia
- Migratory polyarthritis
- Tenosynovitis
- Systemic symptoms

190
Q

Describe the pathophysiology of renal cancer (renal cell carcinoma)

A

Driven by hypoxia in cells = down regulation of tumour suppressors

Arises mainly from the proximal convoluted tubules

Spread through direct invasion into the perinephric tissues, adrenal gland, renal vein or inferior vena cava

191
Q

Name the 3 main types of renal cancer

A

Cell cell - 80%
Papillary - 15%
Chromophobe - 5%

192
Q

Name the causes of renal cancer

A

Most common cause = smoking

Other causes (hypoxia causes)
- industrial exposure to carcinogens
- dialysis
- hypertension
- obesity
- anatomical abnormalities

193
Q

Name the risk factors of renal cancer

A

Smoking
Obesity
Hypertension
End-stage renal failure
Von Hippel-Lindau Disease
Tuberous sclerosis

194
Q

Name the clinical presentation of renal cancer

A

Palpable mass
Flank pain
Haematuria

Other symptoms
- non-specific symptoms of cancer

195
Q

Name the investigations for renal cancer

A

Clinical examination

CT scan

Bloods

Urinalysis

196
Q

Describe the 2 week wait for renal cancer

A

Age over 45 + unexplained visible haematuria + either without a UTI or persisting after treatment for a UTI

197
Q

Describe the staging of renal cancer

A

By CT thorax, abdomen, pelvis.

Stage
1 - < 7cm + confined to kidney
2 - > 7cm + confined to kidney
3 - local spread to nearby tissue but not beyond Gerota’s fascia
4 - spread beyond Gerota’s fascia, including metastases

198
Q

Describe the management of localised renal cancer

A

Surveillance or surgical management

If not surgery
- percutaneous radiofrequency ablation
- laparoscopic/percutaneous cryotherapy
- renal artery embolization

199
Q

Describe the management for metastatic renal cancer

A

Chemotherapy - considered ineffective

Fit patients = nephrectomy + immunotherapy

Biological agents

Mastectomy - surgical removal of solitary metastases

200
Q

Name 5 differential diagnosis of renal cancer

A

Benign renal cyst
Ureteric cancer
Bladder cancer
Angiomyolipoma
Upper urinary tract urothelial tumour

201
Q

Name the complications of renal cancer

A

Spread
- cannonball metastases

Associated with paraneoplastic syndromes
- polycythaemia
- hypercalcemia
- hypertension
- Stauffer’s syndrome

202
Q

Describe syphilis

A

Bacteria - treponema pallidum

Spirochete - spiral shaped bacteria

Gets in through skin or mucous membranes, replicates and disseminates throughout the body

Incubation 21 days

203
Q

Name the transmission routes of syphilis

A

Oral, vagina or anal sex

Vertical transmission

IDVU

Blood transfusions and other transplants (rare)

204
Q

Describe the stages of syphilis

A
  1. Primary - chancre at site of infection
  2. Secondary - systemic symptoms (3-12 weeks)
  3. Latent - no symptoms (can sit in here)
  4. Tertiary - affects many organs
205
Q

Describe the symptoms of tertiary syphilis

A

Several organs affected

Gummatous lesions

Aortic aneurysms

Neurosyphilis

206
Q

Describe the investigations of syphilis

A

Antibody testing
- antibodies for T. pallidum bacteria
- screening

If positive - conformation by
- dark field microscopy
- polymerase chain reaction

207
Q

Describe the management of syphilis

A

1st line - deep IM of benzathine benzylpenicillin

Other management
- full screening of STIs
- advice about avoiding sexual activity
- contact tracing
- prevention for future infections

208
Q

Describe the complications of untreated syphilis

A

Facilitates HIV transmission

Considerable morbidity - cardiovascular, neurological disease

Major cause of miscarriage, stillbirth and perinatal morbidity and mortality (in some parts of the world).

209
Q

Define pathophysiology of pyelonephritis

A

Inflammation of the kidney resulting from bacterial infection.

Inflammation affects the renal pelvis (joined between the kidney and ureter) and parenchyma (tissue).

210
Q

Describe the pathophysiology of pyelonephritis in men

A

Prostatitis and benign prostatic hyperplasia - cause urethral obstruction leads to bacteriuria = pyelonephritis

Dilation and obstruction of the ureter cause inflammation of the kidney parenchyma

211
Q

Name the causes of pyelonephritis

A

Most common - e. coli

Other
- K. pneumonia
- enterococcus
- pseudomonas aeruginosa
- s. saprophyticus
- c. albicans

212
Q

Name the risk factors of pyelonephritis

A

Female sex

Structural urological abnormalities

Vesico-uteric reflux (children)

Diabetes

UTI

Stress incontinence

Pregnancy

Immunosuppression

213
Q

Describe the clinical features of pyelonephritis

A

Lower UTI symptoms

+

Triad
- fever
- loin or back pain
- nausea/vomiting

214
Q

Describe the investigations for pyelonephritis

A

Urine dipstick
- nitrites, leukocytes, blood

Midstream urine
- microscopy, culture and sensitivity

Blood tests
- raised white blood cells and inflammatory markers

Imaging to exclude other pathologies

215
Q

Describe the clinical diagnosis of pyelonephritis

A

History + examination (urine output + urinalysis)

216
Q

Describe the management of pyelonephritis

A

1st line - antibiotics 7-10 days
- cefalexin
- co-amoxiclav/trimethoprim (if culture available)

If sepsis - sepsis 6

217
Q

What is sepsis 6

A

3 tests
- blood lactate level
- blood cultures
- urine output

3 treatments
- oxygen
- empirical broad spectrum IV antibiotics
- IV fluids

218
Q

Describe the differential diagnosis pyelonephritis if it does not respond to treatment

A

Renal abscess

Kidney stone - obstructing the ureter

219
Q

Describe chronic pyelonephritis

A

Recurrent episodes of infection in the kidneys

Leads to scaring of renal parenchyma = chronic kidney disease = can progress to end stage renal failure

Investigation - Dimercaptosuccinic acid

220
Q

Name 5 complications of pyelonephritis

A

Need for catherterisation
Renal failure
Sepsis
Parenchymal renal scarring
Recurrent UTIS

221
Q

Describe complicated UTI

A

Pregnant

Anatomical or functional abnormalities of urinary tract

Indwelling urinary catheter

Renal disease

Predisposing comorbidities

Men

222
Q

Describe uncomplicated UTI

A

Caused by typical uropathogens

Non-pregnant woman

No known relevant anatomical or functional abnormalities of the urinary tract

No predisposing comorbidities

223
Q

Define renal colic

A

Intense wave-like pattern related to the passage of ureteric stones

224
Q

Define renal stones (renal calculi, urolithiasis, nephrolithiasis)

A

Hard stones that form in the renal pelvis, where the urine collects before travelling down the ureters

225
Q

Where is the common place renal stones will become stuck

A

Vesico-uteric junction

226
Q

Describe the types of renal stones

A

80% - calcium based
- calcium oxalate
- calcium phosphate

Others
- uric acid
- struvite
- cystine

227
Q

Describe the 2 main risk factors for developing calcium renal stones

A

Hypercalcaemia
Low urine output

228
Q

Describe the causes of renal stones

A

Response to elevated levels of urinary solutes

Decreased levels of stone inhibitors (citrate, magnesium)

Low urinary volumes and abnormally low or high urinary pH

229
Q

Name the risk factors of renal stones

A

Dehydration
High salt intake
White ancestry
Male sex
Obesity
Crystalluria

230
Q

Describe the clinical features of renal stones

A

Asymptomatic - until get stuck/irritate

Renal colic - presenting complaint
- unilateral loin to groin pain
- colicky

231
Q

Describe the investigations of renal stones

A

Urine dipstick

Blood tests

Imaging

232
Q

Describe the management of renal stones

A

NSAIDs
Antiemetics
Watchful waiting
Tamsulosin - help aid spontaneous passage
Surgical interventions

233
Q

Describe the ongoing treatment of renal stones

A

Dietary modification with adequate hydration

234
Q

Name the 2 key complications of renal stones

A

Obstruction - leading to acute kidney injury

Infection - with obstructive pyelonephritis

235
Q

Define testicular torsion

A

Twisting of the spermatic cord with rotation of the testicle leading to constriction of the vascular supply and time-sensitive ischemia and/or necrosis of testicular tissue

236
Q

Describe the causes of testicular torsion

A

Most common = anatomical defect - ball clapper deformity

Trauma

Exact = unknown

237
Q

Describe the ball clapper deformity

A

Fixation between the testicle and the tunica vaginalis is absent.

Testicle hangs in a horizontal position instead of more vertical

Able to rotate within the tunica vaginalis, twisting the spermatic cord

238
Q

Name 3 risk factors for testicular torsion

A

Age under 25 years

Neonate

Ball clapper deformity

239
Q

Describe the clinical features of testicular torsion

A

Often triggered by an activity - e.g. playing sports

Acute rapid onset of testicular pain
- may be associated with abdominal pain and vomiting

240
Q

Describe the examination findings of testicular torsion

A

Firm swollen testicle
Elevated (retracted) testicle
Absent cremasteric reflex
Abdominal testicular lie
Rotation

241
Q

Describe the investigations of testicular torsion

A

History + physical examination = immediate surgical consultation

Other imaging
- ultrasound

242
Q

Describe the management of testicular torsion

A

Nil by mouth
Analgesia
Urgent assessment
Surgical exploration of the scrotum
- Orchiopexy
- Orchiectomy

243
Q

Describe a key differential diagnosis of testicular torsion

A

Testicular appendix torsion

Most common cause of acute scrotal pain in prepubertal children

Appendix testis - remnant of Mullerian duct

Located on superior pole of the testicle between the testis and epididymis

Mos common appendage to undergo torsion

244
Q

Name differential diagnosis of testicular torsion

A

Testicular appendix torsion
Epididymitis/Epididymo-orchitis
Hydrocele
Varicocele
Testicular cancer
Inguinal hernia

245
Q

Name the complications of testicular torsion

A

Infarction of testicles
Permanent damage/loss of testicle
Infertility secondary to loss of testicle
Recurrent torsion
Cosmetic deformity
Psychological implication

246
Q

Describe a epididymal cyst

A

Fluid filled sac which occurs at the head of the epididymis

If contains sperm = spermatocele

247
Q

Describe the clinical features and examination findings of epididymal cysts

A

Most cases = asymptomatic or present with a lump or ultrasound

Examination findings
- soft, round lump
- at top of testicle
- associated with epididymis
- May be able to transilluminate large cysts

248
Q

Describe the management of epididymal cysts

A

Generally - no treatment

Cause pain and discomfort - removal may be considered

Surgery best avoiding in young men - can cause infertility

249
Q

Define glomerulonephritis

A

Broad term that refers to a group of parenchymal kidney disease - inflammation and damage to glomeruli

250
Q

What is the general pathophysiology of glomerulonephritis

A

Immunological mediated:

Immunoglobin deposits
Inflammatory deposits
Response to immunosuppressive therapy
Evidence from animal models

251
Q

What are the 4 main presentations of glomerulonephritis

A

Nephritic syndrome
Nephrotic syndrome
Asymptomatic urinary abnormalities
Chronic kidney disease

252
Q

Define nephritic syndrome

A

Generic term for inflammation in the kidneys

Descriptive term

NOT diagnosis

Refers to features that occur with nephritis

253
Q

Describe the features of nephritic syndrome

A

Haematuria (blood in urine) - micro/macroscopic

Oliguria - significantly reduced urine output

Proteinuria - protein in urine. Less than 3g/24hrs. Higher protein than this suggests nephrotic syndrome

Fluid retention

254
Q

Name the causes of nephritic syndrome

A

ANCA associated vasculitis

Goodpasture’s disease

Systemic sclerosis

SLE

IgA nephropathy

Post strep

255
Q

Describe ANCA associated vasculitis (nephritic)

A

Antineutrophil cytoplasmic antibodies

Multisystem small vessel vasculitis

256
Q

Describe the clinical features of ANCA associated vasculitis (nephritic)

A

Systemic inflammatory features

Features of other organ involvement

Splinter haemorrhage

Pulmonary oedema

Crescentic glomerulonephritis

257
Q

Describe the diagnosis of ANCA associated vasculitis (nephritic)

A

Serum ANCA - changes correlate with disease activity

Biopsy
- segmental glomerular necrosis with crescent formation

258
Q

Describe the treatment of ANCA associated vasculitis (nephritic)

A

Immunosuppressants

Other - plasma exchange

259
Q

Define Goodpasture’s disease

A

Glomerular injury due to autoimmunity directed against the alpha-3 chain of type IV collagen mediated by both humoral and cellular processes.

Smoking damage more.

260
Q

What is the serology of Goodpasture’s disease (nephritic)

A

Anti-glomerular basement membrane antibodies

261
Q

Name the 2 risk factors for Goodpasture’s disease

A

HLA-DRB1 or DR4

Smoking

262
Q

Describe the clinical features of Goodpasture’s disease (nephritic)

A

Rapidly progressive kidney failure + pulmonary haemorrhage

Active dipstick

Haemoptysis

263
Q

Describe the investigations of Goodpasture’s disease (nephritic)

A

Biopsy - linear deposits of antibody along basement membrane

Serological testing

Important to avoid renal damage

264
Q

Describe the treatment for Goodpasture’s disease (nephritic)

A

Remove antibody = plasma exchange + agents to prevent production

Immunosuppression

265
Q

Describe the pathophysiology of SLE (nephritic)

A

Chronic multisystem disorder

Antinuclear antibodies

266
Q

What is the serology of SLE (nephritic)

A

Anti-nuclear antibody positive

Double stranded DNA antibody positive

Low complement levels - C3,4

267
Q

Name the 4 risk factors for SLE (nephritic)

A

Female sex (commonly effects women in reproductive years)

> 30 years

African descent in Europe or US

Drugs

268
Q

Describe the clinical features of SLE (nephritic)

A

Rash
Arthralgia
Kidney failure
Neurological symptoms
Pericarditis
Pneumonitis

269
Q

Describe the investigations of SLE (nephritic)

A

Bloods
urinalysis
Chest X-ray
ECG

ISPN classification

270
Q

Describe the treatment of SLE (nephritic)

A

Immunosuppression

271
Q

Define IgA nephropathy (nephritic)

A

Presence of dominant or co-dominant mesangial IgA immune deposits, often accompanied by C3 and IgG in association with a mesangial proliferative glomerulonephritis of varying severity.

272
Q

What is Henoch Schoenlein purpura

A

Systemic form of IgA nephropathy

Triad
- Purpuric rash
- Abnormal pain
- Acute kidney injury

Often self limiting

273
Q

What are the risk factors of IgA nephropathy (nephritic)

A

Family history

Male sex

Age 20-30

Asian/white/native American ancestry

IgA vasculitis

Chronic liver disease

HIV infection

274
Q

Describe the clinical features of IgA nephropathy (nephritic)

A

Episodic microscopic haematuria

AKI

275
Q

Describe the treatment of IgA nephropathy (nephritic)

A

1st line - supportive treatment (main - not much medication)

Budesonide

ACE inhibitors (proteinuria)

Statin (cardiovascular)

276
Q

Describe the investigations for IgA nephropathy (nephritic)

A

Urinalysis
Urine microscopy & culture
Basic biochemistry
Immunofluorescence
- diffuse mesangial IgA deposits

277
Q

Define nephrotic syndrome

A

Occurs when the basement membrane in the glomerulus becomes highly permeable resulting in significant proteinuria

Refers to a group of features without specifying the cause

278
Q

What are the clinical features of nephrotic syndrome

A

Heavy proteinuria
- > 3.5g/24 hrs
- OR UPCR of 300-350 mg/mmol

Hypoalbuminemia < 30 g/L

Oedema - peripheral

279
Q

Describe minimal change disease (nephrotic)

A

Most common nephrotic syndrome

Characterised by - heavy proteinuria, oedema, hypalbuminaemia, hyperlipidaemia

280
Q

Name the causes of minimal change disease (nephrotic)

A

90% cases are idiopathic

May be secondary to certain conditions
- Hodgkin’s lymphoma
- leukaemia

281
Q

Name 4 risk factors for minimal change disease (nephrotic)

A

Age > 1 years but < 8 years

Hodgkin’s lymphoma

Leukaemia

Recent viral illness

282
Q

Describe the clinical features of minimal change disease (nephrotic)

A

Onset gradual, often following recent viral illness

Facial swelling with/without puffy hands/or feet

Oedema of the legs

Nausea and vomiting

283
Q

Describe the investigations of minimal change disease (nephrotic)

A

Urinalysis
Biopsy - electron microscopy - fused podocytes

284
Q

Describe the management for minimal change disease (nephrotic)

A

Steroids

2nd line - tacrolimus, cyclosporin, cyclophosphamide or rituximab

285
Q

Describe membranous nephropathy (nephrotic)

A

Thickening of the glomerular capillary wall

IgG complement deposit in subepithelial surface causing leaky glomerulus

286
Q

Describe primary and secondary membranous nephropathy (nephrotic)

A

Primary - glomerular podocyte membrane PLA2R antigen is the targeted antigen

Secondary - Associated with autoimmune conditions, viruses, drugs and tumours

287
Q

Name the risk factors for membranous nephropathy (nephrotic)

A

Male sex
Age > 40 years
HLA-DR3
Autoimmune disease
Hepatitis B and C
Syphilis
Solid organ carcinoma
Medications

288
Q

Describe the diagnosis of membranous nephropathy (nephrotic)

A

Serum PLA2R Ab

Look for secondary causes

Renal biopsy

Other investigations

289
Q

Describe the treatment in low risk membranous nephropathy (nephrotic)

A

Low risk - wait and see

290
Q

Describe the treatment in moderate risk membranous nephropathy (nephrotic)

A

Wait and see OR rituximab OR calcineurin inhibitor +/- glucocorticoids

291
Q

Describe the treatment in high risk membranous nephropathy (nephrotic)

A

Rituximab OR cyclophosphamide + glucocorticoids OR calcineurin inhibitor + rituximab

292
Q

Describe the treatment for very high risk membranous nephropathy (nephrotic)

A

Cyclophosphamide + glucocorticoids

293
Q

Describe the investigations for nephrotic syndromes

A

Bloods

Urine protein: creatinine ratio

Serum and urine electrophoresis

Lupus tests

Anti-phospholipase A2 receptor antibody (membranous)

HpBsAg, HepCAb - Hep B/C associated

294
Q

Define bacteriuria

A

Presence of bacteria in the urine (symptomatic or asymptomatic)

295
Q

Define pyuria

A

Presence of leukocytes in the urine.

Associated with infection

296
Q

Define an uncomplicated UTI

A

Caused by typical pathogens in people with normal urinary tract and kidney function and no predisposing co-morbidities

297
Q

Define a complicated UTI

A

UTI with increased likelihood of complications e.g. persistent infection, treatment failure and recurrent infection

298
Q

Describe the reasons for cystitis

A

Stasis during pregnancy
Low urinary volume - dehydrated
Ureteric stones
Bladder stones or tumour
Obstruction from prostatic hypertrophy
Catheterisation allowing colonisation

299
Q

What’s the common cause of cystitis

A

E.coli > 50%

Proteus 10-15% - associated with renal stones

Klebsiella 10% - hospital/catheter associated

300
Q

Name the risk factors of cystitis

A

Sexual activity
Spermicide use
Post-menopause
Positive family history of UTIs
History of recurrent UTI
Presence of foreign body

301
Q

Describe what would result in an increase risk of cystitis in men

A

Usually due to benign prostatic hypertrophy, urinary tract stones, urological surgery, urethral strictures.

302
Q

Describe catheterisation of an increased risk factor of cystitis in men

A

All become colonised 7-32 days

Cultures should always be sent (not dipstick)

Change of remove catheter when starting treatment

Send a fresh sample

Formation of biofilms

Incomplete voiding

303
Q

How do you prevent catheter associated cystitis

A

Prevent catheterisation

Prevent bacteria - keep closed, remove asap

Prevention of complications - do not treat asymptomatic, catheter replacement

304
Q

Name the clinical features of cystitis

A

Dysuria
New nocturia
Cloudy urine
Frequency, urgency
Suprapubic pain or tenderness
Haematuria

305
Q

Describe the investigations of cystitis

A

Urinalysis
- nitrites
- leucocytes
- blood - haematuria

urine sample

Microscopy

Culture

Sensitivity testing

306
Q

In microscopy for cystitis what presentation of white blood cells would be pyuria

A

10^4 wbc/ml

307
Q

What amount of bacteria in a urine sample would be positive for cystitis (or an infection)

A

10^5 cfu/ml

308
Q

Describe the management of cystitis (uncomplicated UTI)

A

1st line - antibiotics (non pregnant - nitrofurantoin)

Avoid broad spectrum antibiotics

3 days

Advice

309
Q

Cystitis - In asymptomatic bacteriuria what is the treatment in over 65’s

A

Do not treat

310
Q

What is the treatment course of complicated UTI

A

Always send sample for culture

Longer antibiotic course required.

311
Q

Describe the treatment for a UTI in pregnancy

A

Asymptomatic bacteriuria common in pregnancy (should be treated)

Culture rather than dipstick - confirmed with 2nd sample

> 7 days

312
Q

Define urethritis

A

Inflammatory condition of the urethra that results from either infection or trauma

313
Q

What are the infectious cause of urethritis

A

Gonococcal - Neisseria gonorrhoeae

Non-Gonococcal - chlamydia trachomatis and mycoplasma genitalium

314
Q

What are the causes of urethritis

A

STI

Post traumatic
- catheterisation
- instrumentation
- Foreign body insertion
- Vigorous urethral stripping (compression)

315
Q

Name the risk factors for urethritis

A

Age 15-24 years

Female sex

Men who have sex with men

New or multiple sex partners

Prior or current STD

Incosistent condom use

316
Q

Describe the clinical features of urethritis

A

Presents - acute urethral discharge following unprotected sex

Others
Dysuria
Pruritus

317
Q

Describe the investigations of urethritis

A

Urinalysis - positive for leukocyte esterase

Gram stain and culture of urethral discharge and/or urine sediment

NAAT

HIV/syphilis test

318
Q

Describe the management of urethritis

A

Men - all referred to GUM

Empirical treatment for STI
Test for other STI
UTI - treat

319
Q

Name the possible complications of urethritis

A

Untreated gonococcal - disseminate
- arthiritis
- meningitis
- endocarditis

Untreated non-gonococcal
- reactive arthiritis
- infertility

320
Q

Name the differential diagnosis of urethritis

A

UTI
Candida balanitis or vaginitis
Non-infectious urethritis
Nephrolithiasis
Interstitial cystitis
Reactive arthiritis
Chronic prostatitis

321
Q

Define Epididymo-orchitis

A

Result of infection in the epididymis and testicle on one side

Epididymitis - inflammation of the epididymis

Orchitis - inflammation of the testicle

322
Q

Name 4 causes of Epididymo-orchitis

A

E. coli
Chlamydia trachomatis
Neisseria gonorrhoea
Mumps

323
Q

Name the risk factors of Epididymo-orchitis

A

Male 15-30 years
Mumps
Male > 60
Sexual intercourse
Catheterisation
Prostate enlargement
Men who have sex with men

324
Q

Describe the clinical features of Epididymo- orchitis

A

Testicular pain

Dragging or heavy sensation

Swelling of testicle and epididymis

Urethral discharge (think STI)

Systemic symptoms

325
Q

Describe the investigations of Epididymo-orchitis

A

Urine microscopy, culture and sensitivity

NAAT test, Charcoal swab

Saliva swab

Serum antibodies (mumps)

Ultrasound (torsion or tumours)

326
Q

Describe the management of Epididymo-orchitis

A

STI - refer to GUM, treat

Acutely unwell or septic patients = IV antibiotics

Antibiotics e.g. E.coli

Other
- analgesia
- supportive underwear
- reduce physical activity
- abstain from intercourse

327
Q

Define prostatitis

A

Inflammation of the prostate with evidence of recent or ongoing bacterial infection

328
Q

How can prostatitis be classed

A

Acute bacterial - acute infection

Chronic - > 3 months
- chronic prostatitis
- chronic bacterial prostatitis

329
Q

Describe the causes of prostatitis

A

Cause of chronic unclear
- initially triggered by an infection
- inflammation persists after the infection has be resolved

Acute - E.coli

330
Q

Name the risk factors of prostatitis

A

UTI
Benign prostatic enlargement
Urinary tract instrumentation/manipulation

Others
- poor general health/immunosuppression
- smoking and alcohol consumption
- genetics

331
Q

Describe the clinical features of chronic prostatitis

A

Pelvic pain
Lower UTI symptoms
Sexual dysfunction
Pain with bowel movements
Tender and enlarged prostate on examination

332
Q

Describe the clinical features of acute prostatitis

A

Similar symptoms to chronic - come on quicker

Systemic
- fever
- myalgia
- nausea
- fatigue
- sepsis

333
Q

Describe the investigations of prostatitis

A

urine dipstick

Urine microscopy, culture, and sensitivities

NAAT testing

334
Q

Describe the treatment of acute prostatitis

A

Oral antibiotics
- 2-4 wees

Analgesia

Laxatives

335
Q

Describe the treatment of chronic prostatitis

A

Alpha-blockers (tamsulosin)

Analgesia

Psychological treatment (where indicated)

Antibiotics

Laxatives

336
Q

Name the differential diagnosis of prostatitis

A

Benign prostatic hyperplasia
Prostate cancer
UTI
Bladder cancer
Colorectal cancer
Epididymitis/orchitis

337
Q

Describe the pathophysiology of post-strep infection (nephritic)

A

Bacterial infection causing rapid deterioration of kidney function due to an inflammatory response following a strep infection

Type II hypersensitivity reaction

Effects patients under 30

Presents 1-3 weeks after strep infection

338
Q

Describe the cause of post-strep infection (nephritic)

A

Follows strep infection

Skin infections - impetigo

Throat infections - pharyngitis

339
Q

Describe the investigations of post strep infection (nephritic)

A

Anti-streptolysin titre and anti nicotinamide-adenine denuclerotiase - previous strep

C3
Urine analysis
Renal function tests
Imaging

340
Q

Describe the management of post strep infection (nephritic)

A

Pharmacological
- antimicrobials
- diuretics
- antihypertensive medications

Dialysis - if needed

General measures
- salt/water restriction - oedema
- Bed rest and immobilisation
- Throat culture from patient and family

341
Q

Describe the prognosis of post strep infection (nephritic)

A

Patients usually make a full recovery

342
Q

How is IgA nephropathy a differential diagnosis of post strep infection (nephritic)

A

IgA - usually occurs after upper resp tract or GI infection

Post-strep - usually occurs after skin or throat infection

343
Q

Define focal segmental glomerulosclerosis (nephrotic)

A

Chronic pathological process caused by injury to podocytes in the renal glomeruli

344
Q

Describe the pathophysiology of focal segmental glomerulosclerosis

A

Damage to podocyte triggers apoptosis

Causes podocytes to deattach from the glomerular basement membrane and to be destroyed

Numbers decline, glomerular basement membrane is exposed, deposition of collagen.

Glomerular tuft undergoes sclerosis.

345
Q

Describe the causes of focal segmental glomerulosclerosis

A

Primary - idiopathic (unknown cause)

Secondary - underlying cause
- HIV
- obesity
- medications
- maladaptive response to decreased renal mass

346
Q

Describe the clinical features of focal segmental glomerulosclerosis (nephrotic)

A

Manifests initially proteinuria

Progresses to nephrotic syndrome

Then end-stage renal failure

347
Q

Name the risk factors of focal segmental glomerulosclerosis (Nephrotic)

A

Male sex
Black race
Family history
Heroin abuse
Use of known causative agents
Chronic viral infections

348
Q

Describe the investigations of focal segmental glomerulosclerosis (nephrotic)

A

Bloods
- serum urea
- creatinine
- GFR
- serum albumin
- serum lipid profile

Urinalysis
- with microscopy
- urine protein-to-creatinine ratio
- 24 hour urine collection for protein

349
Q

Describe the management of focal segmental glomerulosclerosis (nephrotic)

A

1st line - corticosteroid therapy

2nd line - treatment of underlying cause

350
Q

Name the differential diagnosis of focal segmental glomerulosclerosis (nephrotic)

A

Membranous nephropathy
Minimal change disease
Amyloidosis
Diabetic nephropathy
Membranoproliferative glomerulonephritis
Light chain deposition disease

351
Q

Describe the pathophysiology of diffuse proliferative glomerulonephritis

A

Depends on underlying aetiology

Activated inflammatory process.

Increased cellular proliferation.

Antibodies.

352
Q

What is the most common cause of diffuse proliferative glomerulonephritis

A

Systemic lupus erythematosus

353
Q

What are the associated infections of diffuse proliferative glomerulitis

A

Endocarditis

Hepatitis B

Hepatitis C

354
Q

Describe the clinical features of diffuse proliferative glomerulonephritis

A

Generalised systemic symptoms

Hypertension

Decreased urinary output

Frothy urine (proteinuria)

Generalised body swelling

Pedal oEdema

Microscopic or gross haematuria

355
Q

Describe the investigations of diffuse proliferative glomerulonephritis

A

FBC
U&Es
Urine analysis
24-hour urine protein to creatinine ratio
24 hour urine sample for protein sample
Renal ultrasound

356
Q

What is the gold standard for diagnostic test for diffuse proliferative glomerulonephritis

A

Renal biopsy

With light microscopy, electron microscopy, immunofluorescence study

357
Q

Name the management for (3) diffuse proliferative glomerulonephritis

A

Conservative treatment - ACE inhibitors

Statin

Corticosteroids - then tapered off

358
Q

How can different types of glomerulonephritis be differentiated

A

Can only be differentiated by renal biopsy

359
Q

What is a poor serological indicator of disease in diffuse proliferative glomerulonephritis

A

Low levels of complement

360
Q

Name the complications of diffuse proliferative glomerulonephritis

A

Hypoalbuminemia

Hyperlipidaemia

Clotting disorders due to loss of anti-thrombin III

Renal biopsy complications

End-stage renal disease

361
Q

Define membranoproliferative glomerulonephritis

A

Group of immune-mediated disorders characterised by glomerular basement membrane thickening and proliferative changes on light microscopy

362
Q

Name 3 causes of membranoproliferative glomerulonephritis

A

Idiopathic
Hepatitis C
Autoimmune conditions e.g. SLE

363
Q

What are the investigations of membranoproliferative glomerulonephritis

A

Renal biopsy
Immunofluorescence

364
Q

What would be seen on a renal biopsy of membranoproliferative glomerulonephritis (3)

A

Thickened basement membrane

Thickened mesangium

Tram tracking appearance

365
Q

What would immunofluorescence of membranoproliferative glomerulonephritis

A

Shows subendothelial deposition of IgG

366
Q

Describe the management of membranoproliferative glomerulonephritis

A

Dipyridamole and aspirin

Kidney transplant for patients with end-stage renal disease

367
Q

What is the difference between membranous glomerulonephritis and membranoproliferative glomerulonephritis

A

Membranous glomerulonephritis = basement membrane thickened, mesangium is not

Membranoproliferative = mesangial proliferation

368
Q

Name the types of LUTS

A

Stress incontinence

Urgency incontinence

Mixed incontinence

369
Q

Define stress incontinence

A

Involuntary loss of urine with coughing or sneezing or physical exertion

370
Q

Define urgency incontinence

A

Involuntary loss of urine associated with or immediately proceeded by urgency

371
Q

Name the causes of LUTS

A

No single cause

Increasing age
Pregnancy/vaginal delivery
Obesity
Constipation
Deficiency in supporting tissues
Family history
Smoking

372
Q

Name the causes of overflow incontinence

A

Urinary retention which can be due to bladder outlet obstruction or detrusor underactivity

Medications that can decrease bladder contractility

373
Q

Name causes of urinary retention

A

Most common in men = benign prostatic hyperplasia

Other
- urethral blockage
- drug treatment
- neurogenic causes
- occur postpartum or postoperatively
- conditions that reduce detrusor contractions or interfere with relaxation of the urethra

374
Q

Define the reversible causes of LUTS

A

DIAPPERS

Delirium
Infection
Atrophic vaginitis/urethritis
Psychological
Pharmacological
Endocrine
Restricted mobility
Stool impaction

375
Q

What is the main risk factor of LUTS

A

Older age

376
Q

Name risk factors of LUTS

A

Older age
Obesity
Diabetes
Inflammation
Benign prostatic hyperplasia
Pregnancy and vaginal delivery
Constipation
Family history

377
Q

Name the clinical features of LUTS

A

Hesitancy
Weak flow
Urgency
Frequency
Intermittency
Straining
Terminal dibbling
Incomplete emptying
Nocturia

378
Q

What are the symptoms of storage LUTS

A

Frequency
Nocturia
Urgency

379
Q

Name the features of voiding LUTS

A

Hesitancy
Intermittency
Slow flow
Terminal dribbling
Straining

380
Q

What are the 3 main investigations in LUTS

A

Urinalysis +/- urine culture

Post void bladder scan

Frequency chart

381
Q

What can be used to assess the severity of LUTS in benign prostate hyperplasia

A

International prostate symptom score

382
Q

What is the conservative management of LUTS

A

Weight loss
Fluid modification
Avoid triggers - smoking, bladder irritants
Bladder re-training
Pelvic floor muscle exercises
Containment

383
Q

What is the pharmacological treatment of urgency incontinence

A

Antimuscarinic agents
Mirabegron
Desmopressin

384
Q

What are the differential diagnosis of LUTS

A

Phimosis
Meatal stenosis
Penile cancer
UTI
Upper UTI
Urological cancer
Urological infection
Sciatica
Benign prostate enlargement

385
Q

What are the red flag symptoms of LUTS

A

Abrupt onset
Pelvic pain - constant, worsened or improved with voiding
Haematuria

Phase 2a (15 decks)

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