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Renal > Urology > Flashcards

Urology Flashcards

1
Q

3 common regions for renal stones to get deposited

A

1) Pelviureteric junction (coming out of renal pelvis)
2) Pelvic brim
3) Vesicoureteric junction (going into bladder)

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2
Q

Incidence and peak age, sex of renal stones

A

Lifetime incidence up to 15%
Peak age 20-40
M:F = 3:1

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3
Q

Types of stones

A

Calcium oxalate -75%
Magnesium ammonium phosphate (struvite/triple phosphate) - 15%
Also urate and more

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4
Q

6 x presentation features of renal stones

A

1) Renal Colic
2) UTI (increased risk if voiding impaired)
3) Haematuria
4) Proteinuria
5) Sterile pyuria
6) Anuria

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5
Q

Renal colic features

A

Excruciating ureteric spasms - loin to groin pain
Nausea and vomiting
Often cannot lie still

Renal obstruction - felt in loin
Mid-ureter - like appendicitis or diverticulitis
Lower ureter - bladder irritability and pain in scrotum, penile tip or labia
In bladder or urethra - pelvic pain and dysuria, Strangury (desire but inability to void)

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6
Q

Examination of kidney stones

A

No tenderness usually

May be renal angle tenderness, esp. on percussion if there is retroperitoneal inflammation

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7
Q

Urine dip in kidney stones

A

Usually +ve for blood

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8
Q

Imaging of stones

A

Spiral non-contrast CT is the best (helps exclude ruptured AAA which presents similarly)

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9
Q

Initial management of stones

A

Analgesia - diclofenac or opioids
IV fluids - help pass stone
Antibiotics eg. cefuroxime or gentamicin

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10
Q

Management of stones

A

Most past spontaneously - increase fluid

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11
Q

Management of stones >5mm/pain not resolving

A

Medical expulsive therapy - nifedipine or alpha-blocker (tamsulosin)
This promotes expulsion and reduces analgesia requirements

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12
Q

If still not passing

A

Extracorpeal shockwave lithotripsy - shatters stone - SE: renal injury and may cause DM
Ureteroscopy using basket (if pregnant)
Percutaneous nephrolithotomy - keyhole surgery to remove stones when large, multiple or complex (intracorporeal lithotripsy or stone fragmentation)

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13
Q

Prevention of stones

A

Drink plenty
Normal Ca2+ dietary intake- low stimualtes oxalate excretion
Low salt diet

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14
Q

Prevention of calcium stones

A

Thiazide diuretic used to decrease calcium excretion

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15
Q

What increases oxalate levels? (therefore avoid if oxalate stones)

A 
Chocolate
Tea
Rhubarb
Strawberries 
Nuts 
Spinach
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16
Q

Causes of urinary tract obstruction

A

1) Luminal - stones, sloughed papilla, blood clots, tumour (renal, ureteric or bladder)
2) Mural - stricture, neuromuscular dysfunction
3) Extra mural - Abdominal/pelvic mass or tumour, retroperitoneal fibrosis

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17
Q

Features of acute upper tract obstruction

A

Loin pain radiating to groin
May be superimposed infection which can cause loin tenderness
Or enlarged kidney

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18
Q

Features of chronic upper tract obstruction

A

Flank pain
Renal failure
Superimposed infection
Polyuria due to impaired urinary concentration

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19
Q

Features of acute lower tract obstruction

A

Acute urinary retention
Suprapubic pain
Distended palpable bladder - dull to percuss

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20
Q

Features of chronic lower tract obstruction

A 
Urinary frequency, hesitancy
Poor stream, terminal dribbling 
Overflow incontinence 
Distended palpable bladder
PR may feel large prostate
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21
Q

Imaging of UT obstruction

A

USS

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22
Q

Treatment of UUT obstruction

A

Nephrostomy or ureteric stent
A-blockers (tamsulosin) to reduce stent-related pain from spasm
Pyeloplasty - widen PUJ - if idiopathic PUJ obstruction

23
Q

Treatment of LUT obstruction

A

Catheter insertion - urethral or suprapubic
Treat underlying cause
NB: Large diuresis after relief of obstruction - can cause temporary salt-losing nephropathy

24
Q

What is urinary retention?

A

Not emptying the bladder

Due to obstruction or decreased detrusor power

25
Q

What happens in acute urinary retention?

A

Bladder usually tender and containing about 600ml of urine

26
Q

Causes of acute UR

A 
Prostatic obstruction - usual cause in men 
Urethral strictures 
Anticholinergics 
Psychological 'holding'
Alcohol 
Constipation 
Post op - pain/inflammation or anaesthetics 
Infection 
Neurological - cauda equina syndrome
Carcinoma
27
Q

Examination in acute UR

A

Prostate - DRE
Abdominal exam
Perineal sensation - Cauda test

28
Q

Tricks to aid voiding

A 
Analgesia
Privacy on wards
Ambulation 
Standing 
Running taps or in a hot bath
29
Q

If tricks fail

A

Catheterise
Start alpha-blocker - tamsulosin
after 2-3 days trial without catheter - continue tamsulosin

30
Q

Prevention of acute UR

A

Finasteride - decreased prostate size

Tamsulosin

31
Q

Presentation of chronic UR

A

More insidious and may be painless
Bladder capacity can be >1.5L

Overflow incontinence, acute on chronic retention, lower abdominal mass
UTI
Renal failure

32
Q

Causes of chronic UR

A

Prostatic enlargement - common
Pelvic malignancy
DM
CNS disease

33
Q

Management of chronic UR

A

Only catheterise if pain, urinary infection or renal impairment

Otherwise treat underlying cause

34
Q

Prevalence of benign prostatic hyperplasia

A

Common - 24% aged 40-64

40% 65+

35
Q

What happens in BPH

A

Benign nodular or diffuse proliferation of musculofibrous and glandular layers of the prostate
Inner zone enlarges (unlike outer zone enlargement in prostate carcinoma)

36
Q

Features of BPH

A

LUTS - nocturia, frequency, urgency, post-micturition dribbling, poor stream, overflow incontinence, haematuria and bladder stones - UTI

37
Q

Tests in BPH

A

Rule out cancer - PSA and transrectal USS + biopsy

38
Q

Lifestyle changes in BPH

A

Avoid caffeine and alcohol

Relax when voiding, void twice in a row, practise “holding on”

39
Q

Medication what and when?

A

Mild disease and when waiting for surgery
A-blockers - tamsulosin (doxazosin, terazosin) SE: ED, drowsiness, depression, dry mouth, hypotension, weight gain)

5alpha-reducatase inhibitors -eg. finasteride - prevent testosterone conversion to dihydrotestosterone - reduce prostate size - excreted in semen SE: impotence and decreased libido

40
Q

Surgery in BPH

A

Transurethral resection of prostate - 14% become inpotent - beware of bleeding and TURP syndrome (absorption of washout causing hyponatraemia and fits)

Transurethral incision of prostate - same benefit as TURP but less risk to sexual function and less destruction
- best option for small glands

Retropubic prostatectomy - open operation if prostate very large

Transurethral laser-induced prostatectomy - may be as good as TURP

41
Q

Warnings to patients having TURP

A

Haematuria - first 2 weeks, haematospermia, hypothermia, urethral stricture, post TURP syndrome, infection, ED, incontinence, retrograde ejaculation

Avoid driving and sex for 2 weeks

42
Q

Main cause of incontinence in men

A

Enlargement of prostate

Urge incontinence

43
Q

2 types of incontinence in women

A

Stress incontinence - when raised intraabdominal pressure - eg. coughing, laughing - common in pregnancy and following birth

Urge incontinence/overactive bladder syndrome - urge to urinate quickly followed by emptying of bladder

44
Q

Things which precipitate urgency/leaking in urge incontinence

A 
Coming Home
Cold
Sound of running water
Coffee, tea, coke 
Obesity
45
Q

Cause of urge incontinence

A

Detrusor overactivity (central inhibition decreased or peripheral sensitisation) or a bladder muscle problem

46
Q

Management of stress incontinence

A

Pelvic floor muscle exercises - 8 contractions 3x day for 3 months
Intravaginal electrical stimulation

47
Q

Surgical management of stress incontinence

A

Tension-free vaginal tape - to stabilise mid-urethra

Urethral bulking

48
Q

Medical management of stress incontinence if surgical not an option

A

Duloxetine (SNRI)

49
Q

Management of urge incontinence

A

Look for spinal cord problems and for vaginitis
Bladder training and weight loss = important
Male = consider condom catheter

50
Q

Medical management of urge incontinence

A

Antimuscarinics eg. tolterodine (solifenacin or oxybutynin)

Topical oestrogen - raise bladders sensory threshold

B3 adrenergic agonist - mirabegron - if antimuscarinics CI or unsuccessful

51
Q

Management of urge incontinence if original medical treatment unsuccessful

A

BOTOX

Percutaneous posterior tibial nerve stimulation - if BOTOX not wanted

52
Q

What type of stones does Proteus cause

A

Magnesium ammonium phosphate (struvite) stones

- often form large calculi (staghorn)

53
Q

What type of stones are associated with hyperparathyroidism

A

Calcium phosphate renal stones

Renal (9 decks)

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