UROLOGY 2 Flashcards
List 5 types of renal stones:
Calcium oxalate
Calcium phosphate
Uric acid / urate
Cystine
Struvite
85% of renal stones are ? type:
Calcium oxalate
Which types of renal stones are radiolucent?
Uric acid
Xanthine
Pathophysiology of formation of a struvite stone:
Formed from magnesium, ammonia and phosphate - therefore associated with chronic infection and urease producing bacteria.
Crystals precipitate in the alkaline urine.
Major risk factor for formation of calcium oxalate stones:
Hypercalciuria
Which type of stone is more common in children with inborn errors of metabolism?
Uric acid
Precipitated when the pH is too low
Which type of stone may occur in RTA due to high urinary pH increasing supersaturation of urine with 2 electrolytes?
Calcium phosphate = RTA stone
When a stone is not available for analysis, the urine pH can help guide which type of stone was present:
> 7.2 = struvite
6.5 = cystine
6 = calcium oxalate
5.5 = calcium phosphate
5.5 = uric acid
What type of stone is a staghorn made from, and which 2 infections predispose their formation?
Struvite = Staghorn
Ureaplasma urealyticum
Proteus
Risk factors for renal stones:
Hypercalciuria
Dehydration
RTA
PKD
Hyperparathyroidism, hypercalcaemia
Drugs can both cause and prevent calcium stones, which drugs are these?
Cause: loop diuretics, steroids, acetazolamide and theophylline
Prevent: thiazide diuretics due to increased resorption at the distal tubule
Risk factors for urate stones specifically (2):
gout
ileostomy = loss of bicarbonate and fluid precipitates uric acid
What is the analgesia of choice for renal colic, + further options if not controlled / contraindicated?
NSAIDs first line
IV paracetamol
IM diclofenac inpatient
How do alpha blockers work and when are they indicated in renal colic?
Relax smooth muscle of the ureters, allowing stone to pass.
<10mm stones
Initial non-imaging investigations in suspected renal stones:
Urine dip and culture
U+Es, creatinine, renal function
FBC, CRP for associated infection
Calcium and urate levels
Imaging of renal stones, including time frames and when these differ:
NON-CONTRAST CTKUB within 24 hours.
IMMEDIATE if single kidney, fever, or uncertain about diagnosis e.g. Triple A within differential
What is the imaging of choice for renal stones in pregnancy and childhood?
US
All ureteric stones require input; what is the definitive management for ureteric stones of <10mm and 10-20mm?
<10mm = ESWL +/- alpha-blocker
10-20mm = Ureteroscopy , with stent left in place for 4 weeks
Renal stones are managed based on their size. Discuss the management for <5mm, 5-10mm, 10-20mm and >20mm
<5mm = watchful waiting
5-10mm = ESWL
10-20 = ESWL or ureteroscopy
> 20mm = percutaneous nephrolithotomy (intracorporeal SWL)
Calcium stones may be due to hypercalciuria, which is found in 5-10% of the general population. Give some preventative measures of hypercalciuria.
Hydration
Lemon in drinking water
Reduced carbonated drinks
Reduced salt
Potassium citrate may help
Thiazide diuretics
2 drugs that reduce urinary oxalate secretion:
Cholestyramine
Pyridoxine
Prevention of uric acid stones:
Allopurinol
Oral bicarb causing urinary alkalisation
When should ‘combination therapy’ be used in BPH, and what does it consist of?
Mod-severe symptoms on IPSS and large prostate
Alpha-1 antagonist tamsulosin
5 alpha reductase inhibitor finasteride (effects may take 6m)
Surgical management of BPH;
TURP
Action and adverse effects of finasteride:
Finasteride; reduces conversion of testosterone to DHT which has been shown to induce BPH.
What IPSS score is considered moderate-severe?
> =8
Cause of TURP syndrome, and electrolyte abnormalities observed:
TURP syndrome is caused by excess glycine used during TURP surgery.
Glycine is hypotonic, and it gets into the systemic system via the open prostatic venous sinuses, causing severe symptoms.
Hyponatraemia
Hyperammonia after glycine has been broken down in the liver
Risk factors for developing TURP syndrome.
Surgery >1 hour
Height of bag >70cm
Weight removed 60g
Large blood loss
Perforation
Large amount of fluid used
Poorly controlled congestive heart failure
IPSS scoring system cut offs:
0-7 = mild
8-19 = mod
20-35 = severe
ED can be broadly split into organic, psychogenic and mixed causes. Give 3 factors that favour an organic cause;
Normal libido
Lack of tumescence
Gradual onset
ED can be broadly split into organic, psychogenic and mixed causes. Give 3 factors that favour a psychogenic cause:
Acute onset
Relationship change or difficulty
Spontaneous / self stimulated erections are achieved
Reduced libido
Hx of psychological problems
Hx of premature ejaculation
Cardiovascular risk factors for ED:
Dyslipidaemia
Obesity
Metabolic syndrome
Hypertension
Diabetes
Alcohol
Smoking
2 classes of drugs that are risk factors for ED:
SSRI
BB
Initial investigations for ED:
10 year CV risk, including lipids and fasting glucose level
Free testosterone, taken between 9 and 11 am
Free testosterone was measured in a man who had presented with ED. What tests are recommended next, and what is the further management if these ones are abnormal?
Repeat the free Testosterone
Add FSH, LH and prolactin
If abnormal, refer to endocrinology
What class of drug is sildafenil? 2nd line option for ED?
PDE-5 inhibitor
Vacuum erection device
4 potential departments you could need to refer someone presenting with ED to;
Cardiology - high cardiac risk where sex may be unsafe or PDE-5i is contraindicated.
Mental health services
Endocrinology - low serum testosterone, or abnoramlities of fsh, lh and prolactin
Urology - young man always had problems, penile structural abnormality or abnormal testicular examination
Where does renal cell cancer arise from?
Proximal renal tubular epithelium
Most common histological subtype of renal cell cancer, + 2nd and 3rd:
Clear cell
Papillary
Chromophobe
Classical triad of RCC:
Haematuria
Loin pain
Abdominal mass
Endocrine effects of RCC (3)
EPO secretion causing polycythaemia
PTHrP secretion cause hypercalcaemia (could also be due to bony mets)
ACTH
What is Stauffer syndrome?
LFT derangement without renal mets
Cholestasis, hepatosplenomegaly.
IL-6 increased
A RCC is compressing veins due to mass effect. What is a likely outcome of this?
Varicocele
A RCC has invaded into Gerota’s fascia, what T stage is it?
T4
T1 vs T2 stage RCC:
<=7 confined to kidney =T1
> 7 = confined to kidney = T2
2 structures a T3 RCC would invade into, and 2 that it would not at this stage:
Major veins e.g. renal vein, then IVC, perinephric tissue
NOT into gerota’s fascia or the ipsilateral adrenal gland
Which type of immunotherapy is superior in RCC?
TKI e.g. sorafenib
Risk factors for RCC:
Obesity
Smoking
Von Hippel Lindau
Tuberous sclerosis
Hypertension
End stage renal failure
RCC is the common primary of cannonball mets in the lungs. Give the next most common type of cancer associated with them:
choriocarcinoma (placenta)
Staging scan in RCC:
CT thorax abdo pelvis
Most common bacterial cause of epididymo-orchitis in elderly patients:
E.coli
Epididymo-orchitis is most commonly caused by local spread of sexual infection in young men. 2 organisms, investigations and management:
Chlamydia
Neisseria gonorrhoea
STI screen NAAT swabs
Unknown organism IM CEFTRIAXONE SINGLE DOSE, + ORAL DOXY 14 DAYS
Empirical treatment of elderly patients with epididymo-orchitis:
Send MSU
Oral quinolone for 2 weeks e.g. ofloxacin
