Urology Flashcards
Describe the normal anatomy of the prostate
Walnut-sized gland located between the bladder and the penis in front of the rectum
Urethra runs through the center from the bladder to the penis
Divided into three zones: central, transition and peripheral
What area of the prostate is involved to cause prostatism?
Blockage of urinary outflow, this tells us the problem has to be in the transitional zone surrounding the urethra
What are the common diseases which affect the prostate? What areas are involved in each?
Prostatitis (inflammation)- shows no zonal preference
Benign prostatic hyperplasia- peri-urethral
Adenocarcinoma- outer peripheral part of the gland
What blood test would you perform BEFORE a DRE if you suspected prostate cancer? Why?
Measure serum PSA before doing DRE as the DRE procedure can artefactually elevate the serum PSA level
What are the features of a normal prostate on DRE?
Normal prostate is smooth and has a firm consistency with lateral lobes and a median groove/sulcus between them
What abnormalities can you detect on DRE of the prostate? What types of disease would each of these changes suggest?
Prostatitis can produce and enlarged tender prostate, which may have boggy consistency on DRE
Prostatic hyperplasia produces symmetrical enlargement
A hard, irregular prostate gland is suggestive of prostate cancer, often accompanied by an undetectable median groove/sulcus
Extra-capsular spread of prostate cancer can sometimes be identified by tethering of the rectal mucosa over the prostate
What cancer is most common in the prostate?
Adenocarcinoma
How would you stage the local extent of the prostate cancer? Why this modality?
Prostate MRI is the most accurate way to determine the local extent of the tumour
Patients will also have a trans-rectal ultrasound scan at time of biopsy which will give an indication of the likely local extent of tumour
How would you stage the extent of the systemic spread of prostate cancer?
CT scan of the areas and a radionucleotide bone scan
What are the symptoms of prostatism?
Filling symptoms: urgency, frequency, nocturia or dysuria
Voiding symptoms: poor stream, hesitancy, terminal dribbling, incomplete voiding
Chronic retention patient can experience overflow incontinence
Red flags: hematuria, weight loss
72 y/o F presents to GP with pain on passing urine for 2 days; needing to go much more often, failing to make it to the toilet on time. Denies any fever or chills, but does report some suprapubic pain. No vaginal discharge. T2DM managed with diet alone and osteoarthritis of knees for which she takes ibuprofen PRN. What is the most likely diagnosis?
Urinary tract infection
What is the most common cause of urinary tract infection?
E. coli
What treatment would you give first line for a UTI?
Trimethoprim 200mg bd for 3 days
What do you need to know before commencing nitrofurantoin?
Renal function; drug is contraindicated if eGFR
What are side effects of nitrofurantoin?
Colours urine brown, harmless
Headache, nausea
Potentially serious side effects: pulmonary fibrosis, hepatotoxicity and neuropathy
What is a particular issue with using ciprofloxacin?
Clostridium difficile diarrhoea
What is the commonest organism causing wound infection?
Staph aureus including MRSA
List some risk factors for wound infection
Post operative Obesity Smoking Diabetes Immunocompromise Malnutrition
What is a common side effect of penicillin antibiotics?
Rash
What are antibiotic treatment options for wound infection?
Flucloxacillin
Clindamycin
What are the major side effects of clindamycin?
Nausea and vomiting
Diarrhoea: antibiotic associated diarrhoea and Clostridium difficile
What is the difference between nephrotic and nephritic syndrome?
Nephrotic: Proteinurea (>3.5g in 24hrs), ++++ Protein, Urine looks frothy, Hypoalbuminaemia, albumin lost in urine due to gaps in podocytes, Oedema of ankles & eyes due to loss of albumin so intravascular oncotic pressure ↓and fluid moves out of vessels
Nephritic: Haematuria +++ Blood, May be microscopic or macroscopic, Red cell casts – distinguishing feature, form in nephrons & indicate glomerular damage, Podocytes develop large pores which allow blood & protein through, Proteinurea ++ Protein (small amount), Hypertension usually only mild, Low urine volume
Name some side effects of steroid use
Weight gain Acne Peptic ulcer Hypertension Diabetes Osteoporosis Avascular necrosis Psychosis
What are second line treatment options for autoimmune renal conditions?
Calcineurin inhibitor
Cytotoxic therapy: Alkylating agents, Anti-metabolites
Biologics
What are Cyclosporin and Tacrolimus? And what is their mechanism of action?
Calcineurin inhibitors
Interacts with intracellular proteins: cyclophillin and FK-binding protein
Reduced transcription of cytokine genes e.g. ↓IL1, IL2 and TNF
Reduced clonal proliferation of T cells
What are side effects of Calcineurin inhibitors?
Gum hypertrophy Hyperkalaemia Hypertension Diabetes Nephrotoxic (renal failure) Opportunistic infection Enhance risk of cancer
Name 2 alkylating agents
Cyclophosphamide and Chlorambucil
What is the mechanism of action of alkylating agents?
Crosslinking with DNA
Impairs DNA replication and transcription
Cell death and inhibit proliferation
What are some side effects of alkylating agents?
Lymphopenia Gonadal toxicity SIADH Lymphoma Bladder toxicity & cancer (acrolein – metabolite of cyclophosphamide)
What are Azathioprine and Mycophenolate? And what is their mechanism of action?
Anti metabolites
Interfere with purine nucleic acid metabolism
Reduced proliferation of T cells
What are side effects of anti metabolite drugs?
Hepatic dysfunction
Bone marrow suppression
Opportunistic infection
Cancer
What is the characteristic triad of haemolytic uraemic syndrome?
Haemolysis
Thrombocytopenia
Acute kidney injury
What is shiga toxin? What is the relevance to haemolytic uraemic syndrome?
Toxin produced by either shigella dysenteriae or escherichia coli
Toxins affect vascular endothelial cells, initiate enzyme activation cascade leading to platelet aggregation and consumptive thrombocytopenia. Microvascular obstruction leads to cell death, particularly in the kidneys
What are symptoms of renal disease relating to filtration problems?
Blood in urine Frothy urine Pruritus Insomnia, mental slowing Loss of appetite Nausea, vomiting
What are symptoms of renal disease relating to tubular reabsorption problems?
Swollen legs
Abdominal bloating / swelling
Shortness of breath
Dizziness
What are symptoms of renal disease relating to hormone production?
Malaise
Tiredness
Headaches
Bone pains
What are signs of renal disease relating to filtration problems?
Haematuria +/- Proteinuria Excoriations Muscle twitching Reduced consciousness, seizures Cardiac arrhythmias, pericardial rub Sallow colour, uraemic fetor
What are signs of renal disease relating to tubular reabsorption problems?
Peripheral oedema Anasarca, ascites Pleural effusions Pulmonary oedema- late Tachycardia, Postural BP drop
What are signs of renal disease caused by inadequate hormone production?
Anaemia
Hypertension
What are methods of measuring proteinuria?
Urine dipstick
24 hour urine collection
Albumin-creatinine ratio (ACR) or Protein-creatinine ratio (PCR)
How much protein is usually present in the urine?
Protein
What is orthostatic proteinuria?
Low grade proteinuria
What may cause transient/haemodynamic proteinuria?
Fever
Exercise
Heart failure
Hyperadrenergic state
What would be a glomerular cause for proteinuria? Which protein will be present? And what is this called?
Leak from glomeruli due to damage to filtration barrier
Albumin
Glomerulopathy
What would be a tubular cause for proteinuria? Which protein is present in this case? And what is this called?
Decreased proximal tubular re-absorption due to damage to tubular cells
LMW proteins
Acute tubular necrosis, Tubulo-interstitial nephritis
What would be an overflow cause for proteinuria? Which protein is present in this case? And what might cause this?
Overwhelmed capacity to re-absorb
Increased protein production
Immunoglobulin light chains present
Multiple myeloma
What is the difference between primary and secondary Glomerulopathy?
Primary: pathologic alterations in normal glomerular structure and function, independent of systemic disease processes
Clinical presentation and pathologic findings of glomerulopathies secondary to systemic diseases may mirror primary glomerular disorder
Give and example of a primary and secondary Glomerulopathy
Primary: IgA nephropathy
Secondary: e.g. Diabetic nephropathy
What is nephrotic syndrome?
Proteinuria > 3.5g/day (normal
What structural changes are responsible for proteinuria in nephrotic syndrome?
Damage to endothelial surface, causing loss of negative charge
Damage to glomerular basement membrane
Effacement of foot processes
Why do you see Hypoalbuminaemia in nephrotic syndrome?
Due to urinary losses
Compensatory increased liver albumin synthesis impaired
Leads to salt and water retention
What are some consequences of salt and water retention?
Peripheral oedema, anasarca, ascites, pleural effusions, pulmonary oedema, hypertension
Why does nephrotic syndrome lead to a hypercoagulable state?
Multiple proteins of coagulation cascade have altered levels
Antithrombin III (urinary losses)
Fibrinogen, factor V (more liver synthesis)
Increased platelet aggregation
Haemoconcentration
Why is hyperlipidaemia a clinical feature of nephrotic syndrome?
Urinary losses of HDL
Increased liver synthesis of LDL and VLDL in response to hypoalbuminaemia
Why is infection risk increased in nephrotic syndrome?
Increased due to urinary losses of IgG and complements
What factors increase the risk of acute kidney failure?
Hypovolaemia, sepsis »_space; Acute tubular necrosis
Underlying renal disease
Risk of renal vein thrombosis
More vulnerable to NSAIDs and ACE inhibitors
What is glomerulonephritis?
Inflammation of glomeruli
Glomerular filtration barrier is damaged protein leaks into urine
What are different categories of glomerulonephritis?
Minimal change disease
Membranous nephropathy
Focal segmental glomerulosclerosis
Membranoproliferative glomerulonephritis
What clinical features in the history might you want to enquire about with haematuria?
Abdominal Pain / Loin pain Lower Urinary Tract Symptoms – dysuria, frequency Fever Skin rashes or joint pains Presence of blood clots History of trauma Weight Loss Family History of renal disorders e.g. Polycystic kidney disease, Alports syndrome
What clinical features might you want to investigate with a presentation of haematuria?
Hypertension Fever Skin rashes Joint swelling Signs of salt and water retention Palpable kidneys Presence of proteinuria
Give some causes of haematuria
Urinary Tract Infection / Pyelonephritis Benign Prostatic Hypertrophy (BPH) Renal Stones Urinary Tract Cancer / Bladder Cancer Glomerulonephritis Bleeding Disorders
What are red cell casts?
Red cells squeeze through fenestrations in endothelial cells and cross into Bowman’s space
As they pass down tubule they may become embedded in uromodulin (Tamm-Horsfall protein) and appear in urine as red cell casts
Why might you see dysmorphic red blood cells in the urine in Glomerulonephritis?
Red cells are damaged as they are forced through glomerular filtration barrier and therefore have irregular shapes
What features of haematuria would suggest that it is glomerular in origin?
RBC casts
Dysmorphic RBCs
Brown urine
Associated proteinuria
What features of haematuria would suggest that it is non glomerular in origin?
Presence of blood clots
Reddish / Pink urine
Eumorphic RBCs
What are clinical features of nephritic syndrome?
Haematuria with red blood cell casts (Glomerular in origin)
Proteinuria
Hypertension
Degree of renal insufficiency
What is a typical cause of nephritic syndrome?
Proliferative glomerulonephritis
Proliferation, increased number of cells in glomeruli
What is acute kidney injury?
Significant deterioration in renal function, which is potentially reversible, over a period of hours or days
What are the categories of causes of acute kidney injury?
Pre-renal failure 85%: Hypoperfusion
Intrinsic renal failure 5%: Many causes, ATN
Post-renal failure 10%: Obstruction
What is chronic kidney disease?
Progressive loss of kidney function
Kidneys attempt to compensate with hyperfiltration, with time hyperfiltration results in loss of more function
Loss of volume (shrinkage) of kidney and scarring
Not symptomatic until >70% of combined function of both kidneys lost
What GFR value would put someone into the category of end stage kidney failure?
What are signs and symptoms of chronic kidney disease?
When GFR
Why is itching a symptom of kidney disease?
Dry skin Reduced sweating Abnormal metabolism of calcium and phosphorus Raised parathroid hormone Accumulation of toxins Sprouting of new nerves Systemic inflammation Co-existing medical problems, particularly diabetes and liver disease
What blood test features would you expect to see in chronic kidney disease?
Elevation of Urea and Creatinine Anaemia Raised PTH Low Ca Raised Ph Raised K Low Na Low Bicarbonate Low pH
What are the most common causes of chronic kidney disease?
Diabetes
Hypertension
What may be some causes of loin pain?
Infection - pyelonephritis Renal calculi Urinary Tract Obstruction Tumours Glomerulonephritis Polycystic kidneys Referred pain
What are the symptoms of hypercalcaemia?
Bones: arthralgia, pyrophosphate arthropathy Moans: depression Stones: renal colic Groans: peptic ulceration Constipation, polyuria, nocturia
