Urology Flashcards

Question

Aldosterone

Answer 1

``` Increased Na reabsorption (DT) K Secretion (DT) H2O retention (Weight gain) ```

Answer 2

Peristaltic contraction of ureters smooth muscle The internal urethral “sphincter” is NOT a true sphincter, but is where the smooth muscle at the start of the urethra acts as a sphincter when the smooth muscle is relaxed. The external urethral sphincter is a true sphincter, made up of skeletal muscle under voluntary somatic control.

Answer 3

Overlain with peritoneum Lies in midline posterior to pubic bones Lies anterior to reproductive system and rectum Smooth muscle (Detrusor muscle) Lined transitional epithelium Trigone of bladder - 2 vesicoureteric openings Urethral opening - Vesicoureteric openings 1-2cm oblique passage through muscular wall

Answer 4

Sympathetic supply (hypogastric nerves) - Main function is to prevent reflux of semen into the bladder during ejaculation L1-L3 - inhibit bladder contraction and closes the internal urethral “sphincter” Parasympathetic supply (pelvic nerves) - contraction of detrusor muscle - Pressure within the bladder, S2-S4 Somatic motoneurones (pudendal nerves) - innervate skeletal muscle that forms external urethral sphincter

Answer 5

1. Stretch receptor afferents from the bladder wall. As the bladder fills. Increase discharge in afferent nerves to spinal cord via interneurones a) excitation of parasympathetic outflow b) inhibition of sympathetic outflow c) inhibition of somatic motoneurones to external sphincter d) pathways to sensory cortex  sensation of fullness

Answer 6

Controls plasma osmolarity When the effective OP of the plasma increases, the rate of discharge of ADH-secreting neurones in the SO and PVN increases as well. Increased release of ADH from the posterior pituitary. Changes in neuronal discharge are mediated by osmoreceptors in the anterior hypothalamus, close to the SO and PVN. *Low ECF increases ADH

Answer 7

Acute: Barbiturates + Opiates Chronic: Obstructive lung disease eg bronchitis, emphysema, asthma

Answer 8

Voluntary hyperventilation Aspirin First ascent to altitude

Answer 9

Ketoacidosis Renal failure Diarrhoea

Answer 10

Vomiting (Hypovolaemia - Decreased NaCl) Aldosterone excess Excess HCO3- Massive blood transfusions

Answer 11

Blocks Phosphorus reabsorption in proximal tubule | Increases Calcium reabsorption in distal, collecting tubule and ascending loop of Henle

Answer 12

Ventricullar Fibrillation | Aldosterone is released

Answer 13

Plasma Protein | Diabasic Phosphate

Answer 14

5. 3kPa/40mmHg 7. 4 24mmmol/l

Answer 15

Na, Cl | K+

Answer 16

Secreted eg. penicillin | Reabsorbed eg.urea

Answer 17

Minimal Change Disease

Answer 18

Increased Phosphate | Decreased Calcium

Answer 19

Ciproflaxin Ceftriaxone Gentamicin Co-amoxiclav

Answer 20

Non-muscle invasive tumours: Transurethral resection of bladder tumours (TURBT) + Adjuvant intravesical therapy (e.g. intravesical immunotherapy with BCG, or intravesical chemotherapy with mitomycin C) Muscle-invasive tumours: Cystectomy Neoadjuvent chemotherapy (e.g. cisplatin)

Answer 21

Weakness of pelvic floor muscles Overactive Detrusor Urodynamic Studies eg. Cystometry -leak point pressure +Post Void Residual volume with USS Pelvic floor muscle training (stress UI) Avoid Stimulants eg Alcohol and Caffeine Anticholinergic - Oxybutynin

Answer 22

Urine Dipstick - Haematuria - WBC - nitrites are a sign of UTI - pH urate (acidic), struvite - pseudomonas UTI (alkali) CT KUB FBC, U&E ``` Serum calcium (If high check PTH) Serum phosphate Serum urate (MSSU) microscopy, culture and sensitivity 24-hour urine collection ```

Answer 23

Extracorporeal shock wave lithotripsy (ESWL) Percutaneous nephrolithotomy (PCNL) Ureteroscopic removal with Holmium laser/lithotripsy Open surgery

Answer 24

May be detected at an early stage with PSA screening | May be associated with family history of breast cancer

Answer 25

Urinalysis – dipstick urine Urine microscopy, culture and sensitivity Urine cytology

Answer 26

Pregnancy, Renal insufficiency, Hypersensitivity to iodine contrast

Answer 27

IgA Nephropathy (immediately after pharyngitis)

Answer 28

Renal artery stenosis Sx: Renal Bruit, High BP, Flash Pulmonary Oodema Ix: Ultrasound / Renal Doppler USS Intra-arterial angiography CT or MR angiography Rx: Renal Balloon Angioplasty and Stenting

Answer 29

Light-headedness/dizziness Fatigue Hyperuricaemia – can precipitate gout Hyperglycaemia

Answer 30

``` Ankle oedema (swelling) Postural hypotension ``` Cough – persistent dry cough

Answer 31

Renal disease – renal artery stenosis, chronic kidney disease, acute GN, APKD Endocrine disease – cushing’s syndrome, conn’s syndrome, phaechromocytoma Pregnancy – pre-eclampsia, eclampsia Drugs – corticosteroids, oral contraceptive

Answer 32

ACE inhibitor Angiotensin-2 receptor blocker (ARB) Calcium channel blocker CCB

Answer 33

Recombinant Erythropoietin (EPO) *Vitamin D analogue (e.g. calcitriol) + calcium supplement (hyperparathyroidism and hypocalcaemia due to Vitamin D deficiency)

Answer 34

Cysts in liver – may lead to lLF, and pancreatitis Berry aneurysms and subarachnoid haemorrhage (SAH) Mitral Valve Prolapse)

Answer 35

Haemodialysis Peritoneal dialysis - CAPD – continuous ambulatory - APD - automated peritoneal dialysis) Renal transplantation

Answer 36

Blood cultures/stool cultures: infectious diarrhoea? Arterial blood gas (acidosis) USS of renal tract: rule out obstruction/hydronephrosis, ?signs of CKD (size/structure) Urinary sodium levels/urine osmolality: pre-renal vs. renal cause (low in Pre-renal, high in ATN)

Answer 37

Diabetes (diabetic nephropathy) - Slow Proteinuria Minimal change glomerulonephritis - Children Very sensitive to *steroid management Membranous glomerulonephritis - SLE Focal segmental glomerulosclerosis - ? Systemic amyloidosis - ?

Answer 38

2 (Na + K) + Glucose + Urea (all in mmol/L)

Answer 39

Urine osmolality (>500mmol/kg) Hypercholesterolaemia Hyperproteinaemia Hyperglycaemia

Answer 40

Trimethoprim

Answer 41

Acute pyelonephritis Ciprofloxacin Abx

Answer 42

``` Female gender Diabetes mellitus Pregnancy Catheterisation Sexually active ```

Answer 43

Cancer – e.g. renal cell carcinoma, bladder cancer Renal stone, i.e. urolithiasis IgA nephropathy Trauma to urinary tract

Answer 44

``` Diuretics (loop and thiazide) – most common Renal tubular acidosis (RTA) Excess aldosterone (e.g. Conn’s syndrome) ``` Vomiting and diarrhoea Laxative abuse Alkalosis

Answer 45

U waves (vs. sine waves for hyper-) ST depression Flat T-waves (vs. tented T waves for hyper-)

Answer 46

Renal Profile (minerals, electrolytes, proteins, glucose) Blood Film, ABG, C3+C4 24h-urine collection (protein, creatinine clearance) Urine Dipstick culture and staining USS renal tract and Renal Biopsy SLE Wegener's Granulomatosis (AKI) Vasculitis

Answer 47

ARF, CRF Salt restriction, Fluid monitoring and BP control, Steroids Hypercoagulability (excess glucose binds with proteins), Hypercholesterolaemia, Infection Children - Corticosteroids Diuretics, ACE Inhibitors, Anticoagulation

Answer 48

Pre-renal - Hypovolaemia Sepsis, Renal Artery Stenosis Renal - Parenchyme Acute GN, Nephrotoxins, Radiological Contrast Post-renal - Obstruction to Urine Prostatic Hypertrophy Blockage eg. Catheter, Stones, Clots Rx: Fluid monitoring (CVP line)

Answer 49

``` Pulmonary Oedema K+ > 6.5mmol/L pH < 7.2 Pericarditis Encephalopathy ```

Answer 50

Risk >90 Injury 60 - 89 Failure 30 - 59 Function is lost 15 - 29 End Stage Kidney Disease < 15 Dialysis

Answer 51

afferent and efferent arteriolar diameter a) Sympathetic VC nerves b) Circulating catecholamines - constriction 1rily afferent c) Angiotensin II - constriction, of efferent at [low], both afferent and efferent at [high]

Answer 52

dysuria, urgency, haematuria Frequency (Passing urine more often in small amounts) Suprapubic tenderness, Polyuria (increase volume), UTI is very unlikely if the urine is not cloudy

Answer 53

The high presence of pus cells (neutrophil polymorphs) in urine. Inflammatory response and UTI. Microscopy of unstained urine (cells, casts or organisms) >10 white blood cells/mm3 in urine is significant pyuria

Answer 54

The presence of bacteria in urine. Note that the anterior urethra is not sterile and the presence of urethral organisms in urine washed out during micturition is not bacteriuria. Causes: Indwelling catheters Culture and antibiotic treatment should only be undertaken if the patient is symptomatic (e.g. feverish, suprapubic pain) and/or shows signs of infection (e.g. pyrexial, tachycardic, pyuria in urine specimen). Screening cultures MSU in pregnancy (increased risk of pyelonephritis and premature delivery), patients who are undergoing urological surgery or implantation of artificial prosthesis.

Answer 55

Inflammation of the bladder, could be due to infection Infection of the upper UT involving the kidneys. Pathological condition with renal scarring and potentially loss of renal function. Factors which may contribute include diabetes, Infection vesico-ureteric reflux, and urinary obstruction. Vague abdominal discomfort + Hypertension

Answer 56

any WOMAN with 3 or more symptoms - Abx only 2 symptoms or fewer, should have (MSU) collected Urine Dipstick Nitrite (a metabolic by product of some bacteria) Protein (sign of inflammation or renal pathology) Lecucocytes = pus cells (leucocyte esterase - enzyme found in leucocytes - marker of an inflammatory response) If not all 3 present follow with urine culture MEN with suspected UTI should have an MSU UTI in MEN less common but the incidence increases with age secondary to obstruction caused by prostatic hypertrophy. Recurrent UTI in men may be a presenting feature of prostatitis.

Answer 57

Elderly - coliform organisms In younger males, sexually transmitted organisms such as Chlamydia trachomatis and Neisseria gonorrhoeae

Answer 58

commonest renal disease most commonly affects women of child bearing age. Loin pain and fever, frequency and dysuria less likely Patients may be systemically unwell, the causative organism can spread into bloodstream to cause a bacteraemia. - SEPSIS - nausea, vomiting urine cultured and ABx > aggressive than simple cystitis for at least 7 days Blood cultures if systemically unwell

Answer 59

UTI possible diagnosis in any sick child and every young child with unexplained fever Follow up is important to identify children with vesico-ureteric reflux as this may lead to renal scarring in later life

Answer 60

1. Short urethra and its proximity to the rectum. 2. Trauma to female urethra during childbirth. - Catheters or Cystoscopy 3. In pregnancy, increased frequency of acute renal tract infection due to stasis of urine (progesterone dilating the ureters and physical pressure from the foetus) 4. Anatomical abnormalities (e.g. congenital pelvi-ureteric junction obstruction, vesico-ureteric reflux, duplex kidneys, horseshoe kidney, urethral valves, prostatic enlargement, chronic urinary retention) 5. Renal cysts. 6. Pre-existing renal parenchymal damage (e. g. from recurrent pyelonephritis). 7. Stones in UT, including kidneys, ureter or bladder 8. Immunosuppression including diabetes mellitus, prolonged steroid therapy, transplant rejection medications

Answer 61

``` E.coli Proteus sp. * Enterococcus faecalis Klebsiella sp. * Pseudomonas sp. * ``` * hospital associated - catheters or instrumentation

Answer 62

The urine is -ve on culture but significant numbers of pus cells are present. collect 3 *morning urines for a ZN stain and TB culture sign of non-infective pathology in the bladder / kidneys, including renal tract stone disease, interstitial cystitis, urological malignancy, chronic prostatitis

Answer 63

FEMALES 3-day course Trimethoprim or Nitrofurantoin / Amoxicillin Cephalexin if Pregnant ``` MALES 14-day course Trimethoprim or Nitrofurantoin OR Quinolone (e.g. ciprofloxacin) to cover possibility of prostatitis ```

Answer 64

at least 7 days therapy | ciprofloxacin

Answer 65

voiding LUTS, storage LUTS, incontinence, polyuria - bladder pathology (UTI, interstitial cystitis, bladder cancer) - bladder outflow obstruction 1) Infection/Inflammation - prostatitis, balanitis 2) Iatrogenic/Trauma - pelvic floor damage after traumatic vaginal delivery or hysterectomy, urethral injury from catheterisation or pelvic fracture 3) Neoplasia - prostate cancer, penile cancer 4) Idiopathic - chronic pelvic pain syndrome 5) Obstruction - primary bladder neck obstruction - benign prostatic enlargement (BPE) - urethral stricture, phimosis - neurological causes (i.e. neurogenic bladder dysfunction): i. supra-pontine lesions (stroke, Alzheimer, Parkinson’s) ii. infra-pontine supra-sacral lesions (e. g. spinal cord injury, disc prolapse, spina bifida) iii. infra-sacral (e.g. multiple sclerosis, diabetes, cauda equina compression, surgery to retroperitoneum) - systemic disorders (e.g. chronic renal failure, cardiac failure, diabetes mellitus, diabetes insipidus)

Answer 66

``` Dehydration hypercalciuria, hyperparathyroidism, hypercalcaemia cystinuria high dietary oxalate renal tubular acidosis polycystic kidney disease ``` Drug causes Loop diuretics, steroids, acetazolamide, theophylline Thiazides can prevent calcium stones (increase distal tubular calcium resorption)

Answer 67

Acidosis - bicarb Anaemia – EPO and iron Bone disease – diet and phosphate binders CV risk – BP, aspirin, cholesterol, exercise, weight Death & Dialysis – counsel and prepare Electrolytes – diet and consider drugs Fluid overload – salt and fluid restriction, diuretics Gout – optimise +/- meds Hypertension – weight, diet, fluid balance, drugs Iatrogenic issues – BE AWARE

Answer 68

Investigations MSSU Flow rate study Post-void bladder residual USS Bloods : PSA urea and creatinine (if chronic retention) Renal tract USS if renal failure or bladder stone suspected Flexible cystoscopy if haematuria Urodynamic studies in selected cases TRUS-guided prostate biopsy if PSA raised or abnormal DRE

Answer 69

Medical therapy Alpha blockers 5 alpha reductase inhibitors (Finasteride or Dutasteride) Combination Surgical intervention TURP Gold Standard ** Open retropubic or transvesical prostatectomy (prostate size >100cc) Endoscopic ablative procedures

Answer 70

Cause smooth muscle relaxation and antagonise the ‘dynamic’ element to prostatic obstruction Types : - non-selective (alpha 1 and 2) : phenoxybenzamine - selective short acting : prazosin, indoramin - selective long acting : alfuzosin, doxazosin, terazosin - highly selective (i.e. alpha-1a) : tamsulosin

Answer 71

- Finasteride (5AR Type II inhibitor) - Dutasteride (5AR Type I and II inhibitor) - reduces prostate size and reduces risks of progression of BPE - combination therapy of 5ARIs + alpha blockers most effective in reducing risk of progression of BPE - can also reduce prostatic vascularity and hence reduces haematuria due to prostatic bleeding - potential role in prostate cancer prevention

Answer 72

``` Progression of LUTS Acute urinary retention Chronic urinary retention Urinary incontinence (overflow) UTI Bladder stone Renal failure from obstructed ureteric outflow due to high bladder pressure ```

Answer 73

Painless, palpable and percussible bladder Patients often able to void but with residuals Detrusor underactivity which can be 1ry (i.e. primary bladder failure) or secondary (i.e. due to longstanding BOO, such as BPO or urethral stricture) Presents as LUTS or complications (e.g. UTI, bladder stones, overflow incontinence, post-renal or obstructive renal failure) or incidental finding Immediate treatment is catheterisation Cx: Hyponatraemia, Hyperkalaemia, metabolic acidosis, persistent renal dysfunction due to ATN ``` High pressure Low pressure Painless Painless Incontinent Dry Raised creatine Normal creatine Bilateral hydronephros Normal kidneys ```

Answer 74

Symptoms - Pain - Frank haematuria Signs - Palpable mass - Microscopic haematuria Complications - Infection and sepsis - Renal failure

Answer 75

Resuscitation - ABCs - IV access, bloods, ABG, urine, blood cultures - fluid balance monitoring - IV fluids, broad-spectrum antibiotics - Analgesia - HDU care +/- renal replacement therapy Emergency treatment of obstruction (for unremitting pain or complications) - Percutaneous nephrostomy insertion OR - Retrograde stent insertion Definitive treatment of obstruction - underlying cause - stone – Ureteroscopy + laser lithotripsy / ESWL - ureteric tumour – radical nephro-ureterectomy - PUJ obstruction – laparoscopic pyeloplasty

Answer 76

Percutaneus puncture !bleeding !adjacent organs Usually under LA + sedation US or xray guidance

Answer 77

Resuscitation - ABCs - IV access, bloods, ABG, urine, blood cultures, - Fluid balance monitoring - IV fluids, broad-spectrum antibiotics (if appropriate) - Analgesia - HDU care +/- renal replacement therapy Investigations (imaging: Bladder scan, USS renal tract) Emergency treatment of obstruction (for unremitting pain or complications) - Urethral catheterisation OR - Suprapubic catheterisation Definitive treatment of obstruction - Treat underlying cause - e.g. BPE – TURP - e.g. Urethral stricture – Optical urethrotomy - e.g. Meatal stenosis – Meatal dilatation - e.g. Phimosis – Circumcision

Answer 78

Painful inability to void with a palpable and percussible bladder Main risk factor is BPO which can occur spontaneously or triggered by an unrelated event (eg. constipation, alcohol excess, post-operative, urological procedure) Other RF: UTI, urethral stricture, alcohol excess, post-operative causes, acute surgical or medical problems ``` Immediate catheterisation (urethral / suprapubic) Complications : UTI, post-decompression haematuria, pathological diuresis, renal failure, electrolyte abnorm ``` If no RF, start a-blocker immediately and remove catheter in 2 days (60% will void successfully); if fail to void, recatheterise and organise TURP (after 6 weeks)

Answer 79

Progression of LUTS Acute urinary retention Chronic urinary retention Urinary incontinence UTI Bladder stone RF from obstructed ureteric outflow due to High bladder pressure

Answer 80

Short-term indwelling catheters (up to 2 weeks) Long-term indwelling catheters (up to 3 months)

Answer 81

Renal loss of K+: Diuretics (loop and thiazide) – most common Renal tubular acidosis (RTA) Excess aldosterone (e.g. Conn’s syndrome) GI loss of K+: Vomiting and diarrhoea, Laxative abuse Alkalosis

Answer 82

Urinary bladder and urethra Develops into pronephros (week 4), Mesonephros in trunk region (week 5 to 9) with a duct and tubules. Duct drains into cloaca Grows out of the caudal end of the mesonephric duct and branches to form the renal pelvis, calyces and collecting duct

Answer 83

Pain, emotion, stress, exercise, nicotine, morphine Alcohol, suppresses ADH release.

Answer 84

Muscle mass: athletes vs malnutrition Dietary intake: creatine supplements vs vegetarians Drugs: Some lead to spurious increases as does ketoacidosis.

Answer 85

100mls/min/1.73m2

Answer 86

involves descending pathways which: Stimulate the parasympathetic and: Inhibit the somatic motor neurones thus summating with the stretch receptor effects relaxation of the muscles of the pelvic floor and this may cause a sufficient downward tug on the detrusor muscle to initiate its contraction. Perineal muscles and external sphincter can be contracted voluntarily, preventing urine flow flowing down the urethra or interrupting the flow once urination begins. After urination, female urethra empties by gravity. Urine remaining in the male urethra is expelled by contractions of the bulbocavernosus muscle.

Answer 87

As the bladder fills, it becomes distended and the stretch receptors are increasingly stimulated, until their output becomes great enough to cause bladder contraction via: stimulation of the paraympathetic and: relax the external sphincter by inhibiting the somatic motoneurones. In “leaky” babies, the micturition reflex operates at this level because the higher brain connections have to be established. This is also the case in adult patients with spinal cord transection after the initial period of spinal shock. In an adult the volume of urine in the bladder required to initiate the spinal reflex is  300- 350mls.

Answer 88

3 major types due to neural lesions Interruption of afferent nerves interruption of both afferent and efferent nerves interruption of facilitatory and inhibitory descending pathways from the brain. In all 3 types the bladder contracts but the contractions are generally insufficient to empty the bladder completely and urine is left in the bladder.