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Clinical sciences > Urology > Flashcards

Urology Flashcards

1
Q

Main functions of the kidneys?

A
  1. To eliminate waste material
  2. To regulate volume and composition of body fluid
  3. Endocrine function - EPO, renin, vit D in active form
  4. Autocrine function - endothelin, prostaglandins, renal natriuretic peptide
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2
Q

Why can’t hypotensive or hypovolaemic patients excrete hydrogen and potassium ions?

A

If renal perfusion or glomerular filtration fall, reabsorption of water and sodium by the proximal tubules increases so minimum fluid reaches the distal tubule- which is where potassium and hydrogen are excreted.

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3
Q

Define dysuria

A

Pain on micturition

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4
Q

Define polyuria

A

Excessive urine output of greater than 2.5-3L in 24 hours. Must be differentiated from urinary frequency and nocturia.

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5
Q

Define nocturia

A

Night-time urination

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6
Q

Define oliguria- what are the causes?

A

Low urine output

Caused by AKI or urinary tract obstruction

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7
Q

What are the most common causes of polyuria?

A
  1. Drink too much (polydipsia)
  2. Poorly controlled diabetes mellitus (solute diuresis)
  3. CKD
  4. Diabetes insipidus
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8
Q

Why and how does diabetes insipidus cause polyuria?

A

There is a lack of vasopressin produced by the hypothalamus (stored in pituitary), meaning kidneys fail to concentrate urine and a lot of fluid is lost.

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9
Q

What are the most common causes of nocturia?

A
  1. Drinking too much (polydipsia) especially before bed
  2. Prostatic enlargement (in men over 50)
  3. Congestive cardiac failure - lying down
  4. Sleep apnoea
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10
Q

How can congestive cardiac failure cause nocturia?

A

Oedema around legs and ankles when lie down there is lack of gravity and can go to heart and expand atria. This causes the release of ANP which in turn increases production of urine.

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11
Q

If man has benign prostatic enlargement, what 3 symptoms are they most likely to complain of?

A
  1. Nocturia
  2. Hesistancy
  3. Weak stream
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12
Q

What are the 3 classes of lower urinary tract symptoms and give examples of each

A
  1. Storage e.g. urgency, nocturia
  2. Voiding e.g. weak stream, hesistancy, intermittency
  3. Post-micturition e.g. dribbling
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13
Q

What 3 factors when taking a urology history would be red flags?

A
  1. Haematuria
  2. Pain
  3. Neurological deficit
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14
Q

What four things would you look out for in examination of 55 yo male with BOO?

A
  1. Bladder palpable? - Chronic urinary retention
  2. Urethral meatus stenosis?
  3. Phimosis
  4. Size of prostate and malignant feel?
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15
Q

How would an oliguric patient be managed (in 3 steps)?

A
  1. Exclude obstruction - pass catheter into bladder and large volume of urine released. If patient already catheterised, flush with saline to remove potential blockage
  2. Assess for hypovolaemia - if obstruction is excluded measure blood pressure, pulse, JVP, urinary electrolytes - urine output in response to fluid challenge is measured if hypovolaemic
  3. Management of established AKI - once above causes excluded
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16
Q

What measurement is the best indicator of kidney function and how it is measured?

A

GFR (worked out by creatinine clearance)

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17
Q

What tests can be done in urology to find or investigate underlying pathologies?

A
  1. Urinary tests - dipstick testing, urinary flow rate, post-void bladder residual
  2. Blood tests - U&E’s for creatinine and PSA
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18
Q

What can a urinary dipstick test detect?

A
  1. Proteinuria
  2. Haematuria
  3. Glucose
  4. Ketones
  5. Bilirubin
  6. pH
  7. Nitrites and leucocytes - UTI
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19
Q

Haematuria in different sections of the stream is indicative of different things. What are these?

A

Blood at start of micturition- urethral disease
Blood at end of micturition- bleeding from prostate or bladder base
Blood seen evenly throughout- bleeding from bladder or above

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20
Q

Most common cause of glucosuria?

A

Diabetes mellitus

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21
Q

Red cell casts in urine are pathognomonic for what?

A

Glomerulonephritis

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22
Q

White cell casts in urine may be seen in what?

A

Acute pyelonephritis

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23
Q

How are renal, bladder and prostate tumours staged?

A

CT

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24
Q

How is polycystic kidney disease diagnosed?

A

Ultrasonography

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25
Q

Post void residual volume can be measured by…?

A

Ultrasonography

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26
Q

Define functional bladder capacity. What is the difference between this and anatomical bladder capacity?

A

Functional bladder capacity is the volume of urine released when patient attempts to empty their bladder.

There can be a post void residual volume, meaning that anatomical bladder capacity can often be much larger.

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27
Q

How is polyuria defined? (Calculation)

A

Urine output of >40ml/kg/24 hours (around 2.5-3L a day)

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28
Q

What causes PSA to be raised?

A
  1. BPH
  2. Prostatic cancer
  3. UTI
  4. Prostatitis
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29
Q

What screening tool is used in BPH, and can also be used to suggest management of the patient?

A

IPSS - International prostate symptom score

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30
Q

What is the general management of a patient with mild symptoms of BPH and an IPSS score of between 0 and 7?

A

Watchful waiting - until symptoms become worse

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31
Q

What is the general management of a patient with moderate or severe symptoms of BPH and an IPSS of 8-19?

A
  1. Conservative treatment - fluid management, bladder drill, avoid caffeine
  2. Drugs - alpha 1 blocker and/or 5-alpha reductase inhibitor
  3. Surgery - often TURP - transurethral resection of prostate, open prostatectomy, green light laser, holmium enucleation of prostate
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32
Q

What is the gold standard surgery used in prostate resection?

A

TURP - transurethral resection of prostate

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33
Q

What is the most common side effect of TURP (transurethral resection of prostate)?

A

Retrograde ejaculation

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34
Q

Why are alpha-1-blockers prescribed in BPH? What effect do they have?

A

They are prescribed as contraction of the bladder neck and urethral sphincter is by the sympathetic nervous system (alpha-1 receptors cause this when NAd binds) meaning that if these receptors are blocked, the bladder neck will not contract so will relax to allow voiding.

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35
Q

Why are 5-alpha reductase inhibitors used in BPH and what effect do they have?

A

Cause prostatic cell apoptosis.

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36
Q

At what diameter can a bladder stone (calculi) still be destroyed by lasers, but if it got any bigger would have to be removed by surgery?

A

3cm

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37
Q

What are the main complications if LUTs are not treated?

A
  1. Bladder calculi
  2. UTI
  3. Bladder decompensation
  4. Incontinence
  5. Haematuria
  6. Acute retention
  7. Decreased QoL
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38
Q

What is the difference between acute and chronic urinary retention?

A

Acute = pain, quick onset, >500ml in bladder

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39
Q

What are the two more serious causes of urinary retention to look out for?

A
  1. Prostatic cancer

2. Spinal cord compression

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40
Q

Spinal cord compression is suspected cause of patient’s urinary retention, what other symptoms are likely to be present?

A
  1. Back pain
  2. Radiating pain to legs
  3. Diarrhoea
  4. Loss os perianal sensation
  5. Lack of sphincter control
  6. Leg weakness
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41
Q

Give an example of a pre-renal cause of kidney failure

A

Hypovolaemia

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42
Q

Give an example of a renal cause of kidney failure

A

Kidney damage

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43
Q

Give examples of post renal causes of kidney failure

A

Obstruction of urine outflow - enlarged prostate, kidney stone, bladder tumour or injury

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44
Q

What stimulation causes the bladder neck and urethral sphincters to relax? ie. allow voiding

A

Decreased sympathetic stimulation (NAd). Must note main part of urethral control is under skeletal muscle control.

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45
Q

What stimulation causes the detrusor muscle to contract) i.e. allow voiding

A

Increased parasympathetic stimulation (ACh)

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46
Q

What type of tumour is prostate cancer and where does it arise?

A

Adenocarcinoma. Often multifocal. Arises in peripheral zone of prostate.

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47
Q

Where does prostate cancer most commonly metastasise to?

A

Lymph and bone. Occasionally to lung, liver and brain.

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48
Q

What are the common biomarkers for prostate cancer in both serum and urine?

A

Serum - PSA, PSMA

Urine - PCA3

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49
Q

What is PSA?

A

Serine antigen responsible for liquefication of semen. Small amount found in blood.

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50
Q

If PSA level is over 20, what is the probability that the patient has prostate cancer?

A

90%

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51
Q

Outline the 5 steps in making a prostate cancer diagnosis

A
  1. LUTS present
  2. PSA high
  3. Transrectal ultrasound scan (TRUSS)
  4. Prostate biopsy
  5. Confirmed and then graded (Gleason grading)
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52
Q

What grading system is used in prostate cancer?

A

Gleason

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53
Q

Explain gleason grading in prostate cancer

A

Gleason grading looks at the histological appearance of the most common and second most common cell morphology. A score from 1-5 is given to each, 1 being well differentiated and 5 being poorly differentiated. The scores are then added together.

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54
Q

What is the difference between grading and staging a cancer?

A 
Grading = histological appearance and how they look under the microscope
Staging = how far the tumour has spread and how large it is
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55
Q

What is the difference between a well differentiated tumour and a poorly differentiated tumour and which has the best prognosis?

A

Well differentiated tumours have the best prognosis.

Well differentiated = cells of tumour and organisation of tumour are similar to that of normal tissue structure. This means they are likely to grow at a slower rate.

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56
Q

What are Partin’s normograms?

A

Tables that use the clinical T stage, serum PSA and Gleason score to predice T and N staging.

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57
Q

How are stages T1, T2 and T3 defined in prostate cancer?

A

T1 No palpable tumour on DRE
T2 Palpable tumour, confined to prostate
T3 Palpable tumour extending beyond prostate

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58
Q

What investigations and tests would need to be done in order to stage a prostate cancer?

A

T - DRE
N - MRI/CT
M- Bone scan

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59
Q

Treatments for local prostatic cancer?

A
  1. Radical prostatectomy - open, laparoscopic, robotic
  2. Radiotherapy
  3. Observation
  4. Focal therapy - High intensity ultrasound
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60
Q

Commonest site of metastatic prostate cancer?

A

Bone

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61
Q

Why is there currently no screening programme in UK for prostate cancer?

A
  • Test is neither particularly sensitive or specific - 15% of men that test negative may have cancer
  • Test can find aggressive cancer as well as slow growing cancer that wouldn’t have symptoms or shorten life span
  • Risk of overtreatment - side effects of treatment can be serious (incontinence, sexual dysfunction)
  • Increased anxiety

National screening committee = Risks outweigh benefits currently

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62
Q

What is the treatment for metastatic prostate cancer?

A

Androgen deprivation therapy (ADT)

  • Bilateral orchidectomy
  • GnRH analogue (both antagonist and agonist block secretion due to flare effect)
  • LH antagonist
  • Antiandrogens (peripheral receptor antagonists)
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63
Q

What is the median remission time for patients with metastatic prostate cancer on androgen deprivation therapy?

A

2.5 years

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64
Q

After remission phase of prostate cancer, what is the management?

A

Second line hormone therapy, cytotoxic chemo, bisphosphonates, and palliation (pain, spinal cord compression, ureteric obstruction and anaemia)

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65
Q

What urinary sphincters are present in a female and how is this different to a male?

A

Females have bladder neck but is often very weak, or absent in 1/4. They do however have a distal urethral sphincter that is the entire length of the urethra. It is enforced by the pelvic floor.

Males have both sphincters. The bladder neck prevents retrograde ejaculation.

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66
Q

What is the purpose of the bladder neck in a male?

A

Prevents retrograde ejaculation

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67
Q

What is the most common cause of stress incontinence in women?

A

Sphincter weakness due to birth trauma. Can also be congenital or neurogenic

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68
Q

What is the most common feature of stress incontinence?

A

Small leak of urine when intra-abdominal pressure increases (e.g. when coughing, laughing, standing)

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69
Q

What is the gold standard management of stress incontinence secondary to birth trauma? Other management?

A

Gold standard - pelvic floor exercises

Can also have surgery (sling, artificial sphincter) or duloxetine (SSNARI)

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70
Q

Why is the use of Duloxetine as a treatment for stress incontinence questioned?

A

Bad side effects - nausea

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71
Q

What is the most common cause of stress incontinence in male?

A

Iatrogenic (prostatectomy) or congenital

72
Q

Define urge incontinence

A

Urgency with frequency, with or without nocturia in the absence of local pathology

73
Q

How is detrusor overactivity diagnosed in a patient with an overactive bladder?

A

Cystometry

74
Q

Outline the management for a patient with urge incontinence.

A

In mild cases can do behavioural therapy - less caffeine, alcohol, lose weight.

  1. Antimuscarinics (anticholinergics) e.g. Tolterodone OR Mirabegron (B3 adrenergic antagonist) if anticholinergic contraindicated
  2. Botox
  3. Neuromodulation - percutaneous electrical stimulation into 3rd sacral nerve root - inhibits reflex bladder contraction. Permanent implant if over 50% improvement
  4. Surgery (detrusor myectomy or cystoplasty)
75
Q

In what patients is overflow incontinence often seen?

A

Men with BPH causing outflow obstruction. Will have a distended bladder on examination and will leak small amounts of urine.

76
Q

What is the management of a patient with overflow incontinence?

A

Catheterise immediately or risk of renal failure

77
Q

What part of the brain controls the coordination and completion of voiding?

A

Periaqueductal grey / pontine micturition centre

78
Q

Where is the conus medullaris and what is it?

A

End of the spinal cord. Between L1 and L2

79
Q

What is the significance of the conus medullaris in terms of neuro-urology?

A

If there is a lesion above it (L1-L2) the bladder will be a reflex bladder. If there is a lesion below it, the bladder will become flaccid.

80
Q

A patient has an upper motor neurone lesion (above L1-L2). What is the effect on the bladder?

A
  • Due to nature of lesion, S2-S4 will still be intact, meaning that spinal reflexes to the bladder will still occur
  • However, coordination and completion of voiding is lost
  • Reflex bladder contractions will occur resulting in involuntary urination
  • Detrusor/sphincter dyssynergia
  • Poorly sustained contraction.
81
Q

A patient has a lower motor neurone lesion (below L1-L2). What is the effect on the bladder?

A
  • Reflex bladder contractions and other spinal reflexes e.g. guarding reflex lost
  • Detrusor areflexia (inability to void either completely or fully- fills until overflows)
  • Poor compliance
82
Q

There are many differences in how UMN lesions and LMN lesions affect a patient’s urological functioning. What is the main similarity?

A

Neither allow the bladder to empty effectively

83
Q

Give some causes of a flaccid bladder due to LMN lesion?

A
  • Spina bifida
  • Sacral fracture
  • Transverse myelitis
  • Ischaemic injury
  • Cauda equina syndrome
84
Q

What is autonomic dysreflexia?

A

Excessive hypertension that can occur with UMN lesions above T6

85
Q

How does autonomic dysreflexia often present?

A

Excessive hypertension, headache, flushing

86
Q

What causes autonomic dysreflexia?

A

Overstimulation of the sympathetic nervous system below spinal cord lesion in response to noxious stimuli (actual or potentially tissue damaging event)

87
Q

How is autonomic dysreflexia treated?

A
  • GTN spray (vasodilator)

- Removal of cause

88
Q

Define an ‘unsafe bladder’

A

One that puts the kidneys at risk

89
Q

What 3 factors in the bladder can put the kidneys at risk of damage? (Unsafe bladder)

A
  1. Raised bladder pressure –> hydronephrosis –> renal failure
  2. Vesico-uteric reflux
  3. Chronic infection
90
Q

What are the two potential ways of managing a reflex bladder?

A
  1. Harness reflexes into incontinence device (note may not keep safe)
  2. Suppress reflexes –> flaccid bladder and empty regularly (ISC/LTC)
91
Q

What is the main risk with convene drainage in an incontinent patient?

A

Can develop incomplete bladder emptying- can be dangerous for kidneys

92
Q

What is the main urological management of a tetraplegic patient?

A
  1. Suprapubic indwelling catheter/ urostomy - as they cannot ISC due to loss of hand function
  2. Convene drainage
93
Q

What is the main urological management of a paraplegic patient?

A

Can intermittently self catheterise due to remaining hand function.

a) Suprapubic
b) Convene
c) Supress reflexes (using anticholinergics/mirabegron) –> flaccid bladder and then ISC

94
Q

What is the main management of a patient with neurogenic stress incontinence? (male and female)

A

Male - Artificial sphincter

Female - Autologous sling/ artificial sphincter

95
Q

How is the bladder function affected in a patient with MS?

A

Get neurogenic detrusor overactivity causing urgency and frequency, incomplete bladder emptying –> uti’s and incontinence.

96
Q

What is the urological management of a patient with MS?

A
  1. Anticholinergics
  2. ISC
  3. IDC
97
Q

Name causes of discoloured urine (other than haematuria)

A
  1. Myoglobinuria - due to rhabdomyolysis. Urine is dark in colour
  2. Beeturia - red colour (due to betanin)
  3. Haemoglobinuria - purple colour
  4. Drugs - e.g. rifampicin = red colour
98
Q

What is glomerulonephritis?

A

Inflammation within the glomeruli of the kidney

99
Q

What 3 signs can glomerulonephritis cause?

A
  1. Leaky glomeruli (proteinuria and haematuria)
  2. High blood pressure
  3. Decreasing kidney function (causes 25% of all end stage renal failure)
100
Q

How does glomerulonephritis present (4 conditions)?

A
  1. Acute nephritic syndrome
  2. Nephrotic syndrome
  3. Asymptomatic urinary abnormalities
  4. CKD
101
Q

Most protein (low molecular weight) is reabsorbed where in the nephron?

A

Proximal tubule

102
Q

What is the underlying pathology of glomerulonephritis?

A

Immune mediated inflammation (immunoglobulin deposits, inflammatory cells and responds to treatment)

103
Q

What is the difference between glomerulonephritis and glomerulopathies?

A

Glomerulonephritis is inflammation of the glomeruli, with in glomerulopathies, there is no evidence of inflammation. There is very large overlap.

104
Q

What two hormones have opposite effect on the sodium and water retention of the kidney?

A

Aldosterone and ANP

Aldosterone promotes Na/K pumps, which means increased sodium and water reabsorption and increased potassium secretion in the distal tubule and collecting duct. Also upregulates ENaC’s

ANP increases GFR (dilates afferent and constricts efferent) and decreases sodium and water reabsorption. Also inhibits renin secretion

105
Q

What is the pathology of nephrotic syndrome?

A

Increased filtration of macromolecules across the glomerular capillary wall due to abnormalities of the glomerular podocytes

106
Q

What clinical signs are seen classically in nephrotic syndrome?

A
  1. Massive proteinuria
  2. Hypoalbuminaemia
  3. Oedema
  4. Frothy urine
  5. Hypercholesterolaemia
  6. Hypercoaguable
107
Q

Why is oedema seen in nephrotic syndrome?

A

Increase in capillary permeability as well as sodium retention in collecting tubules.

108
Q

Why is hypercholesterolaemia and a hypercoaguable state seen in a patient with nephrotic syndrome?

A

Nephrotic syndrome leads to massive proteinuria and therefore hypoalbuminaemia. The liver attempts to compensate for this by going into overdrive meaning that there is increased production of clotting factors and of cholesterol.

109
Q

What is the classic presentation of a patient with nephrotic syndrome?

A

Frothy urine, oedema of the ankles, genitals and abdominal wall.

110
Q

The differential diagnoses of nephrotic syndrome are CCF and cirrhosis (see hypoalbuminaemia and oedema). How can you differentiate from these?

A
  1. CCF- JVP is raised unlike in nephrotic syndrome

2. Cirrhosis - will see other signs of chronic liver disease

111
Q

What specific diseases can cause nephrotic syndrome?

A

Minimal change disease, membranous disease, FSGS, amyloid

112
Q

How do you diagnose any form of glomerulonephritis (nephrotic syndrome, acute nephritic syndrome etc)

A

Renal biopsy

113
Q

Management of a patient with nephrotic syndrome?

A
  1. Diuretic (and dietary salt restriction)
  2. Statins (to lower cholesterol)
  3. Warfarin (to anticoagulate)
  4. ACE inhibitor - reduces angiotensin II mediated efferent arteriolar vasoconstriction
  5. Prophylactic ab’s in children - loss of immunoglobulin in urine
114
Q

Why can ACE inhibitors be prescribed in nephrotic syndrome?

A

ACE inhibitors reduce affect of angiotensin II mediated efferent arteriolar vasoconstriction, meaning pressure in glomerulus drops and protein filtered also drops.

115
Q

A typical case of a post-streptococcal glomerulonephritis develops in a child how long after infection?

A

1-3 weeks

116
Q

What are some of the causes of acute nephritic syndrome?

A

ANCA associated vasculitis, goodpasteur’s disease, post-streptococcal infection, SLE, systemic sclerosis

117
Q

What are the main clinical features of a patient with acute nephritic syndrome?

A
  1. Haematuria (visible or non visible) - red cell casts often seen on microscopy
  2. Proteinuria
  3. Hypertension and oedema
  4. Oliguria
  5. Uraemia
118
Q

Patient presents with acute nephritic syndrome. Hypertension is a key clinical feature of these patients, what are some classical features of hypertension?

A
  1. Retinal haemorrhages
  2. LVH
  3. Crepitations in lung
  4. Increased JVP
119
Q

Commonest cause of asymptomatic urine abnormalities?

A

IgA nephropathy

120
Q

Patient presents with urolithiasis. They ask you what their risk of getting it again is?

A

50% lifetime recurrence

121
Q

What is the commonest age to develop kidney stones?

A

30-50

122
Q

Why does urolithiasis occur?

A
  1. Anatomical - horseshoe kidney, duplex , PUJO, spina bifida, obstruction, trauma etc
  2. Urinary factors - dehydration, calcium, urate, cysteine
  3. Infection
123
Q

What is the most common cause of urolithiasis?

A

Dehydration

124
Q

What stone is most commonly found in urolithiasis?

A

Calcium oxalate (65%)

Note: 80% are calcium salts (oxalate or phosphate)

125
Q

Why are uric acid stones in urolithiasis often hard to identify?

A

Are lucent on xray

126
Q

How can urolithiasis be prevented?

A
  1. Reduce salt and protein
  2. Lose weight (reduce BMI)
  3. Overhydrate
  4. Drink citrus fruit juice
  5. Active lifestyle
  6. Include dairy in diet
127
Q

How are uric acid stones removed?

A

Deacidify urine- they will dissolve

128
Q

What is the advice given to patients with cysteine stones?

A
  1. Alkalinise urine
  2. Overhydrate massively - 3.5-4.5L a day
  3. Genetic councilling
129
Q

What form of urolithiasis is genetically linked?

A

Cysteine stones

130
Q

What are the symptoms of a person with urolithiasis?

A
  1. Loin pain/ renal colic
  2. Haematuria (NV)
  3. LUTS (freq/dysuria)
  4. Recurrent infection
  5. Can be asymptomatic
131
Q

Describe the character of the pain often associated with urolithiasis?

A
  1. Colic pain (due to peristaltic ureter)
  2. Unilateral loin pain
  3. Quick onset
  4. Unable to get comfortable
  5. Radidates to groin or tip of urethra
  6. Assosciated with nausea/vomiting
  7. Classic 12/10 pain
132
Q

What are the differential diagnosis of urolithiasis?

A
  1. AAA
  2. Testicular torsion
  3. Ectopic pregnancy
  4. Bowel pathology (diverticulitis/appendicitis)
  5. MSK
133
Q

What is the gold standard imaging in urolithiasis. If the patient was a recurrent stone former how would this gold standard change?

A

Gold standard = NCCT-KUB

If recurrent stone former or pregnant would do ultrasound KUB instead, but is very poor at visualising ureter.

134
Q

What investigations would you do in suspected urolithiasis?

A
  • Urinalysis / MSU
  • FBC, U&E, calcium, uric acid
  • Imaging - NCCT-KUB
135
Q

Why is it so important to do FBC and urinalysis in urolithiasis?

A

MUST identify INFECTION if there is any

PYONEPHRITIS (infection and obstruction)

136
Q

If patient has pyonephritis how would you manage them?

A
  1. IV antibiotics
  2. IVI oxygen (IV injection)
  3. Escalate
  4. Drain (nephrostomy/ ureteric stent)
137
Q

What would cause you to treat a kidney stone?

A
  1. Progression
  2. Symptomatic
  3. Pain
  4. Infection
  5. Obstruction
138
Q

If a kidney stone is between 1-2cm and is symptomatic what is the most suitable method of treatment?

A

ESWL - Extracorporeal shock wave lithotripsy

139
Q

If a kidney stone is symptomatic and larger than 2cm what is the most suitable method of treatment?

A

PCNL - Percutaneous nephrolithotomy

140
Q

If a patient has multiple kidney stones and the function of the kidney is believed to be less than 10-15% what is the most suitable method of treatment?

A

Nephrectomy

141
Q

If a patient has a ureteric stone, at what size would ESWL be used to remove it?

A

<4mm. If less than 4mm is likely to pass on own but any bigger must remove

142
Q

What classification system is used for renal cysts?

A

Bosniak

143
Q

What criteria would classify a UTI as complicated?

A 
Urodynamic or structural abnormality
Pregnant
Male/child
Recurrent
Nosocomial 
Patient immunocompromised
SIRS (systemic inflammatory response syndrome)
Renal disease
144
Q

Pathogens most frequently responsible for UTI?

A

Ecoli or coagulase negative staph

145
Q

What are the two types of pili that bacteria have and what type of infections do they lead to?

A

Type 1 pili = Lower UTI

Type P pili = Upper UTI

146
Q

What host factors mean that bacteria can adhere more successfully and cause UTI?

A

a) Oestrogen depletion (leads to loss of lactobacilli and increase in pH)
b) HLA blood group antigen non secretor (recurrent UTI)

147
Q

In menopause what happens that means UTI’s are more likely?

A
  1. pH rises (loss of lactobacilli) - due to decreased oestrogen
  2. Increased colonisation by colonic flora
  3. Reduction in mucus secretion
  4. Increased receptivity to UPEC (uropathogenic ecoli) on vaginal mucosa
148
Q

How does the body naturally defend against UTI?

A
  1. Antegrade flushing of urine
  2. Tamm Horsfall protein - traps mannose sensitive bacteria
  3. GAG layer
  4. Low pH and high osmolarity of urine
  5. Commensal flora
  6. Urinary IgA
149
Q

What is pyuria?

A

Presence of leucocytes in the urine, associated with infection

150
Q

In what conditions is sterile pyuria most commonly seen?

A

STI / viral infection

151
Q

Asymptomatic bacteriuria without pyuria (presence of leucocytes) is rarely a concern, apart from one exception?

A

In pregnancy - any bacteriuria should be treated

152
Q

What are the common symptoms of cystitis?

A

Dysuria, frequency, urgency, suprapubic pain, haematuria, cloudy urine

153
Q

What are the common symptoms of pyelonephritis?

A

High fever, rigors, vomiting, loin pain and tenderness

154
Q

Common symptoms in prostatitis?

A

Flu-like symptoms, low back ache, few urinary symptoms, swollen or tender prostate

155
Q

How is UTI diagnosed?

A

Generally is symptoms –> urinalysis
Nitrites and leucocytes is highly predictive of acute infection

–> gold standard = MSU MC&S

156
Q

Main treatment for uti? and adjunctive advice?

A

Trimethoprim

Advice: increase fluid intake, void pre and post intercourse, avoid spermicides

157
Q

What are the guidelines for what is classed as recurrent UTI?

A

> 2 episodes in 6 months

>3 episodes in 12 months

158
Q

How would you investigate recurrent UTI?

A
  1. MSU
  2. Examination including DRE/PV
  3. Post void bladder scan
  4. USS of of renal tract and pelvis and XR/CT of KUB. Could also do flexible cytoscopy

Gold standard = contrast enhanced CT

159
Q

What patients with UTI require renal imaging?

A

Complicated UTI, recurrent UTI and patients with fever/symptoms after 48-72 hours of treatment

160
Q

What is the management of patients with recurrent UTI?

A
  1. Advice - increase fluid intake, regular voiding, post intercourse, avoid spermicides or perfumed soaps
  2. GAG replacement
  3. Oestrogen replacement (vaginal)
  4. Proanthocyadins (cranberry)
  5. Low dose/postcoital AB prophylaxis
  6. Self start AB therapy
  7. Uro-vaxom (extract of ecoli to boost immune system against)
161
Q

How does acute bacterial prostatitis present?

A

Systemically unwell, fevers, rigors, voiding LUTS, pelvic pain, boggy tender prostate

162
Q

How does chronic bacterial prostatitis present?

A

Symptoms for greater than 3 months, recurrent UTI, pelvic pain, voiding LUTS, uropathogens in urine

163
Q

How does chronic pelvic pain syndrome (chronic abacterial prostatitis) present?

A

Chronic pelvic pain. Can have LUTS, can have UTIs

164
Q

What are the stages of NIDDK classification of prostatitis?

A 
I = acute bacterial prostatitis
II = chronic bacterial prostatitis
III = chronic pelvic pain syndrome
IV = asymptomatic inflammatory prostatitis
165
Q

What are the investigations and imaging that could be done in suspected prostatitis?

A
  1. Urinalysis and MSU
  2. Segmented urine/semen cultures
  3. Bloods
  4. STI screen

Imaging: TRUSS +- CT abdo/pelvis

166
Q

Treatment of acute and chronic prostatitis?

A

Acute: Gentamycin and co-amoxiclav (IV). 2-4 weeks Quinolone once well
Chronic: Quinolone 4-6 weeks

167
Q

What are the symptoms of urethritis?

A

Urethral pain, dysuria, discharge

168
Q

What is the most common cause of urethritis? and management?

A

STI

Best managed by GUM

169
Q

What is the main differential diagnosis of epididymo-orchitis?

A

Testicular torsion

170
Q

What are the most common causes of epididymo-orchitis? (age dependent)

A

<35 STI

>35 UTI - elderly often catheter related

171
Q

How would suspected epididymo-orchitis be investigated?

A

1st void urine -> CT/ NG PCR + urethral swab
MSU
Ultrasound to rule out abscess

172
Q

What is the treatment for epididymo-orchitis for both STI and non STI related?

A

STI related –> Doxycycline + azithromycin

Non STI related –> Quinolone

173
Q

What is the classical triad of symptoms seen in pyelonephritis?

A
  1. Loin pain
  2. Fever
  3. Pyuria

can also have sever headache, systemic upset and rigors

174
Q

What 3 investigations/imaging techniques would be used in diagnosing pyelonephritis?

A
  1. PV - rule out tubal/ovarian/appendix pathology
  2. Bloods inc cultures
  3. Ultrasound urgent - to rule out obstruction
175
Q

Treatment for pyelonephritis?

A 
IV gentamycin + co-amoxiclav
Drain obstructed kidney
Catheter if compromised
Analgesia
Oral abx when well
176
Q

What is emphysematous pyelonephritis?

A

Gas forming organisms e.g. C.perfringens –> life threatening. Emergency nephrectomy must be done

177
Q

What is the most common cause of pyelonephritis in children?

A

Reflux

Clinical sciences (10 decks)

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