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AC1 > Urology > Flashcards

Urology Flashcards

1
Q

Describe the normal anatomy of the prostate

A

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

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2
Q

What area of the prostate is involved to cause prostatism?

A

Blockage of urinary outflow, this tells us the problem has to be in the transitional zone surrounding the urethra

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3
Q

What are the common diseases which affect the prostate? What areas are involved in each?

A

Prostatitis (inflammation)- shows no zonal preference
Benign prostatic hyperplasia- peri-urethral
Adenocarcinoma- outer peripheral part of the gland

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4
Q

What blood test would you perform BEFORE a DRE if you suspected prostate cancer? Why?

A

Measure serum PSA before doing DRE as the DRE procedure can artefactually elevate the serum PSA level

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5
Q

What are the features of a normal prostate on DRE?

A

Normal prostate is smooth and has a firm consistency with lateral lobes and a median groove/sulcus between them

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6
Q

What abnormalities can you detect on DRE of the prostate? What types of disease would each of these changes suggest?

A

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

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7
Q

What cancer is most common in the prostate?

A

Adenocarcinoma

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8
Q

How would you stage the local extent of the prostate cancer? Why this modality?

A

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

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9
Q

How would you stage the extent of the systemic spread of prostate cancer?

A

CT scan of the areas and a radionucleotide bone scan

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10
Q

What are the symptoms of prostatism?

A

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

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11
Q

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?

A

Urinary tract infection

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12
Q

What is the most common cause of urinary tract infection?

A

E. coli

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13
Q

What treatment would you give first line for a UTI?

A

Trimethoprim 200mg bd for 3 days

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14
Q

What do you need to know before commencing nitrofurantoin?

A

Renal function; drug is contraindicated if eGFR

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15
Q

What are side effects of nitrofurantoin?

A

Colours urine brown, harmless
Headache, nausea
Potentially serious side effects: pulmonary fibrosis, hepatotoxicity and neuropathy

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16
Q

What is a particular issue with using ciprofloxacin?

A

Clostridium difficile diarrhoea

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17
Q

What is the commonest organism causing wound infection?

A

Staph aureus including MRSA

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18
Q

List some risk factors for wound infection

A 
Post operative
Obesity
Smoking 
Diabetes
Immunocompromise
Malnutrition
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19
Q

What is a common side effect of penicillin antibiotics?

A

Rash

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20
Q

What are antibiotic treatment options for wound infection?

A

Flucloxacillin

Clindamycin

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21
Q

What are the major side effects of clindamycin?

A

Nausea and vomiting

Diarrhoea: antibiotic associated diarrhoea and Clostridium difficile

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22
Q

What is the difference between nephrotic and nephritic syndrome?

A

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

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23
Q

Name some side effects of steroid use

A 
Weight gain
Acne
Peptic ulcer
Hypertension
Diabetes
Osteoporosis
Avascular necrosis
Psychosis
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24
Q

What are second line treatment options for autoimmune renal conditions?

A

Calcineurin inhibitor
Cytotoxic therapy: Alkylating agents, Anti-metabolites
Biologics

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25
Q

What are Cyclosporin and Tacrolimus? And what is their mechanism of action?

A

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

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26
Q

What are side effects of Calcineurin inhibitors?

A 
Gum hypertrophy
Hyperkalaemia
Hypertension
Diabetes
Nephrotoxic (renal failure)
Opportunistic infection
Enhance risk of cancer
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27
Q

Name 2 alkylating agents

A

Cyclophosphamide and Chlorambucil

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28
Q

What is the mechanism of action of alkylating agents?

A

Crosslinking with DNA
Impairs DNA replication and transcription
Cell death and inhibit proliferation

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29
Q

What are some side effects of alkylating agents?

A 
Lymphopenia
Gonadal toxicity
SIADH
Lymphoma
Bladder toxicity & cancer (acrolein – metabolite of cyclophosphamide)
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30
Q

What are Azathioprine and Mycophenolate? And what is their mechanism of action?

A

Anti metabolites
Interfere with purine nucleic acid metabolism
Reduced proliferation of T cells

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31
Q

What are side effects of anti metabolite drugs?

A

Hepatic dysfunction
Bone marrow suppression
Opportunistic infection
Cancer

32
Q

What is the characteristic triad of haemolytic uraemic syndrome?

A

Haemolysis
Thrombocytopenia
Acute kidney injury

33
Q

What is shiga toxin? What is the relevance to haemolytic uraemic syndrome?

A

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

34
Q

What are symptoms of renal disease relating to filtration problems?

A 
Blood in urine
Frothy urine
Pruritus
Insomnia, mental slowing
Loss of appetite
Nausea, vomiting
35
Q

What are symptoms of renal disease relating to tubular reabsorption problems?

A

Swollen legs
Abdominal bloating / swelling
Shortness of breath
Dizziness

36
Q

What are symptoms of renal disease relating to hormone production?

A

Malaise
Tiredness
Headaches
Bone pains

37
Q

What are signs of renal disease relating to filtration problems?

A 
Haematuria +/- Proteinuria
Excoriations
Muscle twitching
Reduced consciousness, seizures
Cardiac arrhythmias, pericardial rub
Sallow colour, uraemic fetor
38
Q

What are signs of renal disease relating to tubular reabsorption problems?

A 
Peripheral oedema
Anasarca, ascites
Pleural effusions
Pulmonary oedema- late
Tachycardia, Postural BP drop
39
Q

What are signs of renal disease caused by inadequate hormone production?

A

Anaemia

Hypertension

40
Q

What are methods of measuring proteinuria?

A

Urine dipstick
24 hour urine collection
Albumin-creatinine ratio (ACR) or Protein-creatinine ratio (PCR)

41
Q

How much protein is usually present in the urine?

A

Protein

42
Q

What is orthostatic proteinuria?

A

Low grade proteinuria

43
Q

What may cause transient/haemodynamic proteinuria?

A

Fever
Exercise
Heart failure
Hyperadrenergic state

44
Q

What would be a glomerular cause for proteinuria? Which protein will be present? And what is this called?

A

Leak from glomeruli due to damage to filtration barrier
Albumin
Glomerulopathy

45
Q

What would be a tubular cause for proteinuria? Which protein is present in this case? And what is this called?

A

Decreased proximal tubular re-absorption due to damage to tubular cells
LMW proteins
Acute tubular necrosis, Tubulo-interstitial nephritis

46
Q

What would be an overflow cause for proteinuria? Which protein is present in this case? And what might cause this?

A

Overwhelmed capacity to re-absorb
Increased protein production
Immunoglobulin light chains present
Multiple myeloma

47
Q

What is the difference between primary and secondary Glomerulopathy?

A

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

48
Q

Give and example of a primary and secondary Glomerulopathy

A

Primary: IgA nephropathy
Secondary: e.g. Diabetic nephropathy

49
Q

What is nephrotic syndrome?

A

Proteinuria > 3.5g/day (normal

50
Q

What structural changes are responsible for proteinuria in nephrotic syndrome?

A

Damage to endothelial surface, causing loss of negative charge
Damage to glomerular basement membrane
Effacement of foot processes

51
Q

Why do you see Hypoalbuminaemia in nephrotic syndrome?

A

Due to urinary losses
Compensatory increased liver albumin synthesis impaired
Leads to salt and water retention

52
Q

What are some consequences of salt and water retention?

A

Peripheral oedema, anasarca, ascites, pleural effusions, pulmonary oedema, hypertension

53
Q

Why does nephrotic syndrome lead to a hypercoagulable state?

A

Multiple proteins of coagulation cascade have altered levels
Antithrombin III (urinary losses)
Fibrinogen, factor V (more liver synthesis)
Increased platelet aggregation
Haemoconcentration

54
Q

Why is hyperlipidaemia a clinical feature of nephrotic syndrome?

A

Urinary losses of HDL

Increased liver synthesis of LDL and VLDL in response to hypoalbuminaemia

55
Q

Why is infection risk increased in nephrotic syndrome?

A

Increased due to urinary losses of IgG and complements

56
Q

What factors increase the risk of acute kidney failure?

A

Hypovolaemia, sepsis &raquo_space; Acute tubular necrosis
Underlying renal disease
Risk of renal vein thrombosis
More vulnerable to NSAIDs and ACE inhibitors

57
Q

What is glomerulonephritis?

A

Inflammation of glomeruli

Glomerular filtration barrier is damaged protein leaks into urine

58
Q

What are different categories of glomerulonephritis?

A

Minimal change disease
Membranous nephropathy
Focal segmental glomerulosclerosis
Membranoproliferative glomerulonephritis

59
Q

What clinical features in the history might you want to enquire about with haematuria?

A 
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
60
Q

What clinical features might you want to investigate with a presentation of haematuria?

A 
Hypertension
Fever
Skin rashes
Joint swelling
Signs of salt and water retention
Palpable kidneys
Presence of proteinuria
61
Q

Give some causes of haematuria

A 
Urinary Tract Infection / Pyelonephritis
Benign Prostatic Hypertrophy (BPH)
Renal Stones
Urinary Tract Cancer / Bladder Cancer
Glomerulonephritis
Bleeding Disorders
62
Q

What are red cell casts?

A

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

63
Q

Why might you see dysmorphic red blood cells in the urine in Glomerulonephritis?

A

Red cells are damaged as they are forced through glomerular filtration barrier and therefore have irregular shapes

64
Q

What features of haematuria would suggest that it is glomerular in origin?

A

RBC casts
Dysmorphic RBCs
Brown urine
Associated proteinuria

65
Q

What features of haematuria would suggest that it is non glomerular in origin?

A

Presence of blood clots
Reddish / Pink urine
Eumorphic RBCs

66
Q

What are clinical features of nephritic syndrome?

A

Haematuria with red blood cell casts (Glomerular in origin)
Proteinuria
Hypertension
Degree of renal insufficiency

67
Q

What is a typical cause of nephritic syndrome?

A

Proliferative glomerulonephritis

Proliferation, increased number of cells in glomeruli

68
Q

What is acute kidney injury?

A

Significant deterioration in renal function, which is potentially reversible, over a period of hours or days

69
Q

What are the categories of causes of acute kidney injury?

A

Pre-renal failure 85%: Hypoperfusion
Intrinsic renal failure 5%: Many causes, ATN
Post-renal failure 10%: Obstruction

70
Q

What is chronic kidney disease?

A

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

71
Q

What GFR value would put someone into the category of end stage kidney failure?

A
72
Q

What are signs and symptoms of chronic kidney disease?

A

When GFR

73
Q

Why is itching a symptom of kidney disease?

A 
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
74
Q

What blood test features would you expect to see in chronic kidney disease?

A 
Elevation of Urea and Creatinine
Anaemia
Raised PTH
Low Ca
Raised Ph
Raised K
Low Na
Low Bicarbonate
Low pH
75
Q

What are the most common causes of chronic kidney disease?

A

Diabetes

Hypertension

76
Q

What may be some causes of loin pain?

A 
Infection - pyelonephritis
Renal calculi
Urinary Tract Obstruction
Tumours
Glomerulonephritis
Polycystic kidneys
Referred pain
77
Q

What are the symptoms of hypercalcaemia?

A 
Bones: arthralgia, pyrophosphate arthropathy 
Moans: depression
Stones: renal colic
Groans: peptic ulceration 
Constipation, polyuria, nocturia

AC1 (18 decks)

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