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Year 3 Medicine lectures > Urology and Renal conditions > Flashcards

Urology and Renal conditions Flashcards

1
Q

Renal and uro conditions:

A
  • Acute kidney injury (AKI)
  • Amyloidosis
  • Benign prostatic hyperplasia
  • Bladder cancer
  • Chronic kidney disease (CKD)
  • Epididymitis and orchiditis
  • Glomerulonephritis
  • Hydrocoele
  • Nephrotic syndrome
  • Polycystic kidney disease
  • Prostate cancer
  • Renal artery stenosis
  • Renal cell carcinoma
  • Testicular cancer
  • Testicular torsion
  • Urinary tract calculi
  • Urinary tract infection
  • Varicocoele
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2
Q

Acute kidney injury:

Define

A
  • An abrupt loss of kidney function resulting in the retention of urea and other nitrogenous waste products and the dysregulation of extracellular volume and electrolytes.
    • NOTE: this can occur in patients with previously normal kidneys or in patients with pre-existing renal disease
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3
Q

Acute kidney injury:

Define

A
  • An abrupt loss of kidney function resulting in the retention of urea and other nitrogenous waste products and the dysregulation of extracellular volume and electrolytes.
    • NOTE: this can occur in patients with previously normal kidneys or in patients with pre-existing renal disease
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5
Q

AKI Classification:

A
  • KDIGO Classification of AKI
    • Increase in serum creatinine > 26 mmol/L within 48 hrs
    • Increase in serum creatinine to > 1.5 times baseline within the preceding 7 days
    • Urine volume < 0.5 ml/kg/hr for 6 hours
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6
Q

Explain the aetiology/risk factors of AKI:

A
  • Pre-Renal (90%)
    • Hypovolaemia (e.g. haemorrhage, severe vomiting)
    • Heart failure
    • Cirrhosis
    • Nephrotic syndrome
    • Hypotension (e.g. shock, sepsis, anaphylaxis)
    • Renal hypoperfusion (e.g. NSAIDs, ACE inhibitors, ARBs, renal artery stenosis)
  • Intrinsic Renal
    • Glomerular - glomerulonephritis, haemolytic uraemic syndrome
    • Tubular - acute tubular necrosis
    • Interstitial - acute interstitial nephritis (e.g. NSAIDs, autoimmune)
    • Vasculitides (e.g. Wegener’s granulomatosis)
    • Eclampsia
  • Post-Renal (due to obstruction)
    • Calculi
    • Urethral stricture
    • Prostatic hypertrophy or malignancy
    • Bladder tumour
  • RISK FACTORS
    • Age
    • Chronic kidney disease
    • Comorbidities (e.g. heart failure)
    • Sepsis
    • Hypovolaemia
    • Use of nephrotoxic medications
    • Emergency surgery
    • Diabetes mellitus
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7
Q

Summarise the epidemiology of AKI

A
  • 15% of adults admitted to hospital will develop an AKI
  • Most common in the ELDERLY
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8
Q

Recognise the presenting symptoms of AKI

A
  • Depends on underlying CAUSE
  • Oliguria/anuria
    • NOTE: abrupt anuria suggests post-renal obstruction
  • Nausea/vomiting
  • Dehydration
  • Confusion
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9
Q

Recognise the signs of AKI on physical examination

A
  • Hypertension
  • Distended bladder
  • Dehydration - postural hypotension
  • Fluid overload (in heart failure, cirrhosis, nephrotic syndrome) - raised JVP, pulmonary and peripheral oedema
  • Pallor, rash, bruising (vascular disease)
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10
Q

Identify appropriate investigations for AKI

A
  • Urinalysis
    • Blood - suggests nephritic cause
    • Leucocyte esterase and nitrites - UTI
    • Glucose
    • Protein
    • Urine osmolality
  • Bloods
    • FBC
    • Blood film
    • U&Es
    • Clotting
    • CRP
    • Immunology
      • Serum immunoglobulins and protein electrophoresis - for multiple myeloma
        • Also check for Bence-Jones proteins in the urine
      • ANA - associated with SLE
        • Also check anti-dsDNA antibodies (high in active lupus)
      • Complement levels - low in active lupus
      • Anti-GBM antibodies - Goodpasture’s syndrome
      • Antistreptolysin-O antibodies - high after Streptococcal infection
    • Virology - check for hepatitis and HIV
  • Ultrasound
    • Check for post-renal cause
    • Look for hydronephrosis
  • Other Imaging
    • CXR - pulmonary oedema
    • AXR - renal stones
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11
Q

Generate a management plan for AKI

A
  • Treat the cause
  • FOUR main components to management:
    • Protect patient from hyperkalaemia (calcium gluconate)
    • Optimise fluid balance
    • Stop nephrotoxic drugs
    • Consider for dialysis
  • Monitor serum creatinine, sodium, potassium, calcium, phosphate and glucose
  • Identify and treat infection
  • Urgent relief of urinary tract obstruction
  • Refer to nephrology if intrinsic renal disease is suspected
  • Renal Replacement Therapy (RRT) considered if:
    • Hyperkalaemia refractory to medical management
    • Pulmonary oedema refractory to medical management
    • Severe metabolic acidaemia
    • Uraemic complications
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12
Q

Identify possible complications of AKI

A
  • Pulmonary oedema
  • Acidaemia
  • Uraemia
  • Hyperkalaemia
  • Bleeding
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13
Q

Summarise the prognosis for patients with AKI

A

Summarise the prognosis for patients with AKI

  • Inpatient mortality varies depending on cause and comorbidities
  • Indicators of poor prognosis:
    • Age
    • Multiple organ failure
    • Oliguria
    • Hypotension
    • CKD
  • Patients who develop AKI are at increased risk of developing CKD
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14
Q

Summarise the prognosis for patients with AKI

A

Summarise the prognosis for patients with AKI

  • Inpatient mortality varies depending on cause and comorbidities
  • Indicators of poor prognosis:
    • Age
    • Multiple organ failure
    • Oliguria
    • Hypotension
    • CKD
  • Patients who develop AKI are at increased risk of developing CKD
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15
Q

Identify possible complications of AKI

A
  • Pulmonary oedema
  • Acidaemia
  • Uraemia
  • Hyperkalaemia
  • Bleeding
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16
Q

Generate a management plan for AKI

A
  • Treat the cause
  • FOUR main components to management:
    • Protect patient from hyperkalaemia (calcium gluconate)
    • Optimise fluid balance
    • Stop nephrotoxic drugs
    • Consider for dialysis
  • Monitor serum creatinine, sodium, potassium, calcium, phosphate and glucose
  • Identify and treat infection
  • Urgent relief of urinary tract obstruction
  • Refer to nephrology if intrinsic renal disease is suspected
  • Renal Replacement Therapy (RRT) considered if:
    • Hyperkalaemia refractory to medical management
    • Pulmonary oedema refractory to medical management
    • Severe metabolic acidaemia
    • Uraemic complications
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17
Q

Identify appropriate investigations for AKI

A
  • Urinalysis
    • Blood - suggests nephritic cause
    • Leucocyte esterase and nitrites - UTI
    • Glucose
    • Protein
    • Urine osmolality
  • Bloods
    • FBC
    • Blood film
    • U&Es
    • Clotting
    • CRP
    • Immunology
      • Serum immunoglobulins and protein electrophoresis - for multiple myeloma
        • Also check for Bence-Jones proteins in the urine
      • ANA - associated with SLE
        • Also check anti-dsDNA antibodies (high in active lupus)
      • Complement levels - low in active lupus
      • Anti-GBM antibodies - Goodpasture’s syndrome
      • Antistreptolysin-O antibodies - high after Streptococcal infection
    • Virology - check for hepatitis and HIV
  • Ultrasound
    • Check for post-renal cause
    • Look for hydronephrosis
  • Other Imaging
    • CXR - pulmonary oedema
    • AXR - renal stones
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18
Q

Recognise the signs of AKI on physical examination

A
  • Hypertension
  • Distended bladder
  • Dehydration - postural hypotension
  • Fluid overload (in heart failure, cirrhosis, nephrotic syndrome) - raised JVP, pulmonary and peripheral oedema
  • Pallor, rash, bruising (vascular disease)
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19
Q

Recognise the presenting symptoms of AKI

A
  • Depends on underlying CAUSE
  • Oliguria/anuria
    • NOTE: abrupt anuria suggests post-renal obstruction
  • Nausea/vomiting
  • Dehydration
  • Confusion
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20
Q

Summarise the epidemiology of AKI

A
  • 15% of adults admitted to hospital will develop an AKI
  • Most common in the ELDERLY
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21
Q

Explain the aetiology/risk factors of AKI:

A
  • Pre-Renal (90%)
    • Hypovolaemia (e.g. haemorrhage, severe vomiting)
    • Heart failure
    • Cirrhosis
    • Nephrotic syndrome
    • Hypotension (e.g. shock, sepsis, anaphylaxis)
    • Renal hypoperfusion (e.g. NSAIDs, ACE inhibitors, ARBs, renal artery stenosis)
  • Intrinsic Renal
    • Glomerular - glomerulonephritis, haemolytic uraemic syndrome
    • Tubular - acute tubular necrosis
    • Interstitial - acute interstitial nephritis (e.g. NSAIDs, autoimmune)
    • Vasculitides (e.g. Wegener’s granulomatosis)
    • Eclampsia
  • Post-Renal (due to obstruction)
    • Calculi
    • Urethral stricture
    • Prostatic hypertrophy or malignancy
    • Bladder tumour
  • RISK FACTORS
    • Age
    • Chronic kidney disease
    • Comorbidities (e.g. heart failure)
    • Sepsis
    • Hypovolaemia
    • Use of nephrotoxic medications
    • Emergency surgery
    • Diabetes mellitus
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22
Q

AKI Classification:

A
  • KDIGO Classification of AKI
    • Increase in serum creatinine > 26 mmol/L within 48 hrs
    • Increase in serum creatinine to > 1.5 times baseline within the preceding 7 days
    • Urine volume < 0.5 ml/kg/hr for 6 hours
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23
Q

Bladder Cancer

Define bladder cancer

A
  • Malignancy of bladder cells
    • Most bladder cancers are transitional cell carcinomas
    • RARELY, bladder cancers may be squamous cell carcinomas associated with chronic inflammation (e.g. schistosomiasis)
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24
Q

Explain the aetiology/risk factors of bladder cancer

A
  • UNKNOWN
  • Risk Factors
    • Smoking
    • Dye stuffs (naphthylamines and benzidine)
    • Cyclophosphamide treatment
    • Pelvic irradiation
    • Chronic UTIs
    • Schistosomiasis
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25
Q

Summarise the epidemiology of bladder cancer

A
  • 2% of cancers
  • 2nd most common cancer of the genitourinary tract
  • 2-3 x more common in MALES
  • Peak incidence: 50-70 yrs
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26
Q

Recognise the presenting symptoms of bladder cancer

A
  • Painless macroscopic haematuria
  • Irritative/storage symptoms
    • Frequency
    • Urgency
    • Nocturia
  • Recurrent UTIs
  • Rarely: ureteral obstruction
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27
Q

Recognise the signs of bladder cancer on physical examination

A
  • Often NO SIGNS
  • Bimanual examination may be performed as part of disease staging
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28
Q

Identify appropriate investigations for bladder cancer

A
  • Cystoscopy - allows visualisation, biopsy or removal
  • Ultrasound
  • Intravenous urography
  • CT/MRI for staging
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29
Q

Prostate Cancer

Define prostate cancer

A
  • Primary malignant neoplasm of the prostate gland
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31
Q

Explain the aetiology/risk factors of pancreatic cancer

A
  • UNKNOWN
  • Risk Factors
    • Age
    • Afro-Caribbean
    • Family history
    • Dietary factors
    • Occupational exposure to cadmium
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32
Q

Summarise the epidemiology of prostate cancer

A
  • COMMON
  • 2nd most common cause of male cancer deaths
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33
Q

Recognise the presenting symptoms of prostate cancer

A
  • Often ASYMPTOMATIC
  • Lower Urinary Tract Obstruction
    • Frequency
    • Hesitancy
    • Poor stream
    • Terminal dribbling
    • Nocturia
  • Metastatic Spread
    • Bone pain
    • Cord compression
    • Systemic symptoms: malaise, anorexia, weight loss
    • Paraneoplastic syndromes (e.g. hypercalcaemia)
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34
Q

Recognise the signs of prostate cancer on physical examination

A
  • Asymmetrical hard nodular prostate
  • Loss of midline sulcus
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35
Q

Identify appropriate investigations for prostate cancer

A
  • Bloods
    • FBC
    • U&Es
    • PSA
      • NOTE: not a very specific test for prostate cancer
    • Acid phosphatase
    • LFTs
    • Bone profile
  • CT/MRI Scan
    • Assesses extent of local invasion and lymph node involvement
  • Transrectal Ultrasound and Needle Biopsy
  • Isotope Bone Scan - check for bone metastases
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36
Q

Renal Cell Cancer

Define renal cell cancer

  • Primary malignancy of the kidneys

Explain the aetiology/risk factors of renal cell cancer

A
  • Renal clear cell carcinoma (80%) - UNKNOWN CAUSE
  • Papillary carcinoma (10%) - UNKNOWN CAUSE
  • Transitional cell carcinoma (10%)
    • NOTE: these occur at the renal pelvis
  • Risk Factors
    • Associated with certain inherited conditions:
      • von Hippel-Lindau disease
        • Mutation in the von Hippel-Lindau protein, which causes headaches, balance issues, dizziness, limb weakness, vision problems and high blood pressure
      • Tuberous sclerosis
        • A rare genetic disease that causes benign tumours to grow in the brain and other organs (e.g. skin, kidneys, lungs, eyes)
      • Polycystic kidney disease
      • Familial renal cell cancer
      • Smoking
      • Chronic dialysis
    • NOTE: renal cell cancer can cause abnormal LFTs in the absence of liver metastases = Strauffer’s Syndrome
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37
Q

Summarise the epidemiology of renal cell cancer

A
  • UNCOMMON
  • 3% of all adult malignancies
  • Peak incidence: 40-60 yrs
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38
Q

Recognise the signs of renal cell cancer on physical examination

A
  • Palpable renal mass
  • Hypertension
  • Plethora
  • Anaemia
  • A left-sided tumour can obstruct the left testicular vein as it joins the left renal vein, and cause a left-sided varicocoele
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39
Q

Identify appropriate investigations for renal cell cancer

A
  • Urinalysis
    • Haematuria
    • Cytology
  • Bloods
    • FBC
    • U&Es
    • Calcium
    • LFTs
    • High ESR (in 75%)
  • Abdominal Ultrasound
    • Best first-line investigation
    • Can distinguish between solid masses and cystic structures
  • CT/MRI
    • Useful for staging
      • Staging system: Robson Staging
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40
Q

Testicular Cancer

Define testicular cancer

A
  • Malignant tumour of the testes
  • Types:
    • Seminomas - 50%
    • Non-seminomatous germ-cell tumours and teratomas - 30%
    • RARE: gonadal stromal tumours (Sertoli and Leydig cell tumours) and non-Hodgkin’s lymphoma
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41
Q

Recognise the presenting symptoms of renal cell cancer

A
  • Renal Cell Carcinoma
    • Usually present LATE
    • Asymptomatic in 90%
    • Triad of Symptoms:
      • Haematuria
      • Flank pain
      • Abdominal mass
  • Transitional Cell Carcinoma
    • Presents EARLIER with haematuria
  • Systemic Signs of Malignancy
    • Weight loss
    • Malaise
    • Paraneoplastic syndromes (e.g. fever, hypercalcaemia, polycythaemia)
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45
Q

Explain the aetiology/risk factors of testicular cancer

A
  • UNKNOWN
  • Risk Factors
    • Maldescended testes
    • Ectopic testes
    • Atrophic tests
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46
Q

Summarise the epidemiology of testicular cancer

A
  • UNCOMMON
  • 1% of male malignancies
  • Common age of onset: 18-35 yrs
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47
Q

Recognise the presenting symptoms of testicular cancer

A
  • Swelling or discomfort of the testes
  • Backache due to para-aortic lymph node enlargement
  • Lung metastases –> SOB, haemoptysis
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48
Q

Recognise the signs of testicular cancer on physical examination

A
  • Painless, hard testicular mass
  • There may be a secondary hydrocoele
  • Lymphadenopathy (e.g. supraclavicular, para-aortic)
  • Gynaecomastia (tumour produces hCG)
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49
Q

Identify appropriate investigations for testicular cancer

A
  • Bloods
    • FBC
    • U&Es
    • LFTs
    • Tumour Markers
      • a-fetoprotein
      • b-hCG
      • LDH
  • Urine Pregnancy Test - will be positive if the tumour produces b-hCG
  • CXR - show lung metastases
  • Testicular Ultrasound
    • Allows visualisation of the tumour
    • Can see associated hydrocoele
  • CT Abdomen and Thorax - allows staging
    • Staging System: Royal Marsden Hospital Staging
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50
Q

Benign Prostatic Hyperplasia

Define benign prostatic hyperplasia

A
  • Slowly progressive nodular hyperplasia of the periurethral (transitional) zone of the prostate gland
  • It is the most frequent cause of LUTS in adult males
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51
Q

Explain the aetiology/risk factors of benign prostatic hyperplasia

A
  • UNKNOWN
  • Link with hormonal changes (e.g. androgens)
  • Risk Factors: reduced risk with soya/vegetable based diets and negative association with cirrhosis
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52
Q

Summaries the epidemiology of benign prostatic hyperplasia

A
  • COMMON
  • 70% of men > 70 yrs have histological BPH (50% of them will experience symptoms)
  • More common in the west than the east
  • More common in Afro-Caribbeans
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53
Q

Recognise the presenting symptoms of benign prostatic hyperplasia

A
  • Obstructive Symptoms
    • Hesitancy
    • Poor or intermittent stream
    • Terminal dribbling
    • Incomplete voiding
  • Irritative/Storage Symptoms
    • Frequency
    • Urgency
    • Urge incontinence (leakage of urine that accompanies an intense desire to pass water with failure of restraint)
    • Nocturia
  • TIP: the obstructive and irritative symptoms can be remembered using the mnemonic FUND HIPS
    • Frequency
    • Urgency
    • Nocturia
    • Dysuria
    • Hesitancy
    • Incomplete voiding
    • Poor stream
    • Smell/odour
  • Acute Retention Symptoms
    • Sudden inability to pass urine
    • Associated with SEVERE PAIN
  • Chronic Retention Symptoms
    • Painless
    • Frequency - with passage of small volumes of urine
    • Nocturia is a major feature
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54
Q

Recognise the signs of benign prostatic hyperplasia on physical examination

A
  • DRE - the prostate is usually smoothly enlarged with a palpable midline groove
  • NOTE: there is poor correlation between the size and the severity of the symptoms
  • Signs of Acute Retention
    • Suprapubic pain
    • Distended, palpable bladder
  • Signs of Chronic Retention
    • A large distended painless bladder (volume > 1 L)
    • Signs of renal failure
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55
Q

Identify appropriate investigations for benign prostatic hyperplasia

A
  • Urinalysis
    • Check for UTI signs and blood
  • Bloods
    • U&Es - check for impaired renal function
    • PSA
  • Midstream Urine
    • MC&S
  • Imaging
    • US of urinary tract (check for hydronephrosis)
    • Bladder scanning to measure pre- and postvoiding volumes
    • Transrectal Ultrasound Scan (TRUS) - allows assessment of bladder size and volume
    • Flexible Cystoscopy
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56
Q

Generate a management plan for benign prostatic hyperplasia

A
  • In Emergency (acute urinary retention)
    • Catheterisation
  • Conservative (if mild)
    • Watchful waiting
  • Medical
    • Selective a-blockers (e.g. tamsulosin) relax the smooth muscle of the internal urinary sphincter and prostate capsule
    • 5a-reductase inhibitors (e.g. finasteride) will inhibit the conversion of testosterone to dihydrotestosterone, which can reduce prostate size by around 20%
  • Surgery
    • TURP
    • Open prostatectomy
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57
Q

Identify possible complications of benign prostatic hyperplasia

A
  • Recurrent UTI
  • Acute or chronic urinary retention
  • Urinary stasis
  • Bladder diverticula
  • Stone development
  • Obstructive renal failure
  • Post-obstructive diuresis
  • Complications of TURP
    • Retrograde ejaculation (you ejaculate up into your bladder because the internal urinary sphincter is relaxed)
    • Haemorrhage
    • Incontinence
    • TURP syndrome
      • DEFINITION: seizures or cardiovascular collapse caused by hypervolaemia and hyponatraemia due to absorption of glycine irrigation fluid
    • Urinary infection
    • Erectile dysfunction
    • Urethral stricture
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58
Q

Summarise the prognosis for patients with benign prostatic hyperplasia

A
  • Mild symptoms are usually well controlled medically
  • Most patients get significant relief from surgery
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59
Q

Chronic Kidney Disease

Define chronic kidney disease (CKD)

A
  • Progressive loss of kidney function over a period of months or years
  • The definition is based on the presence of kidney damage or decreased kidney function (i.e. eGFR < 60 ml/min per 1.73 m2) for three months or more
  • Classification of CKD
    • Stage 1: Normal
      • eGFR > 90 ml/min per 1.73 m2 with other evidence of CKD (microalbuminuria, proteinuria, haematuria, structural abnormalities, biopsy showing glomerulonephritis)
    • Stage 2: Mild Impairment
      • eGFR 60-89 ml/min per 1.73 m2 with other evidence of CKD
    • Stage 3a: Moderate Impairment
      • eGFR 45-59 ml/min per 1.73 m2
    • Stage 3b: Moderate Impairment
      • eGFR 30-44 ml/min per 1.73 m2
    • Stage 4: Severe Impairment
      • eGFR 15-29 ml/min per 1.73 m2
    • Stage 5: Established Renal Failure
      • eGFR < 15 ml/min per 1.73 m2 or on dialysis
60
Q

Explain the aetiology/risk factors of CKD

A
  • In developed countries it is mainly associated with:
    • Age
    • Diabetes mellitus
    • Hypertension
    • Obesity
    • Cardiovascular disease
  • Other risk factors:
    • Arteriopathic renal disease
    • Nephropathies
    • Family history
    • Neoplasia
    • Myeloma
    • Systemic disease (e.g. SLE)
    • Smoking
    • Chronic use of NSAIDs
61
Q

Summarise the epidemiology of CKD

A
  • COMMON
  • Risk increases with age
  • Often associated with other diseases (e.g. cardiovascular disease)
62
Q

Recognise the presenting symptoms of CKD

A
  • Often ASYMPTOMATIC
  • May be an incidental finding of a routine blood or urine test
  • Symptoms of Severe CKD:
    • Anorexia
    • Nausea and vomiting
    • Fatigue
    • Pruritus
    • Peripheral oedema
    • Muscle cramps
    • Pulmonary oedema
  • Sexual dysfunction is common
63
Q

Recognise the signs of CKD on physical examination

A
  • Physical examination rarely reveals many clues
  • May show signs of underlying disease (e.g. SLE)
  • May show complications of CKD (e.g. anaemia)
  • Signs of CKD:
    • Skin pigmentation
    • Excoriation marks
    • Pallor
    • Hypertension
    • Peripheral oedema
    • Peripheral vascular disease
64
Q

Identify appropriate investigations for CKD

A
  • Assessment of Renal Function
    • Urea - not ideal because it varies massively depending on hydration status and diet
    • Creatinine - useful but has limitations. Renal function can drop considerably with minimal change in serum creatinine
    • Isotopic GFR - GOLD STANDARD but expensive
  • Biochemistry
    • Glucose - check for undiagnosed diabetes and diabetic control
    • Potassium - raised
    • Also check sodium, bicarbonate, calcium, phosphate
  • Serology
    • Antibodies
      • ANA - SLE
      • c-ANCA - granulomatosis with polyangiitis (Wegener’s)
      • Anti-GBM - Goodpasture’s syndrome
    • Hepatitis serology
    • HIV serology
  • Urinalysis
    • Check for proteinuria/haematuria
    • 24 hr urine collection
    • Serum or urine protein electrophoresis - check for multiple myeloma
  • Imaging
    • Ultrasound - check for structural abnormalities
    • CT/MRI
    • X-Ray KUB - check for stones
  • Renal Biopsy
65
Q

Epididymitis and Orchitis

Define epididymitis and orchitis

A
  • Inflammation of the epididymis or testes
    • 60% of epididymitis is associated with orchitis
    • Most cases of orchitis are associated with epididymitis
67
Q

Explain the aetiology/risk factors of epididymitis and orchitis

A
  • Most cases are INFECTIVE in origin
  • Bacterial
    • If < 35 yrs: Chlamydia and Gonococcus
    • If > 35 yrs: mainly coliforms (e.g. Enterobacter, Klebsiella)
    • RARE: TB, syphilis
  • Viral
    • Mumps
  • Fungal
    • Candida if immunocompromised
  • 1/3 are IDIOPATHIC
  • Risk Factors
    • Diabetes
    • Rare: vasculitis (e.g. Henoch-Schonlein purpura)
68
Q

Summarise the epidemiology of epididmytis and orchitis

A
  • COMMON
  • Affects all age groups
  • Most commonly: 20-30 yrs
69
Q

Recognise the presenting symptoms of epididymitis and orchitis

A
  • Painful, swollen and tender testis or epididymis
  • NOTE: less acute onset than testicular torsion
  • Penile discharge
  • IMPORTANT: ask about sexual history
70
Q

Recognise the signs of epididymitis and orchitis on physical examination

A
  • Swollen and tender epididymis or testis
  • Scrotum may be erythematous and oedematous
  • Pyrexia
  • Walking will be painful
  • Eliciting a cremasteric reflex may be painful
71
Q

Identify appropriate investigations for epididymitis and orchitis

A
  • Urine
    • Dipstick
    • Early morning urine collections for MC&S
  • Bloods
    • FBC - high WCC
    • High CRP
    • U&Es
  • Imaging
    • Increased blood flow on duplex examination
72
Q

Generate a management plan for epididymitis and orchitis

A
  • Medical
    • Antibiotics
  • Surgical
    • Exploration of testicles if testicular torsion cannot be excluded clinically
    • Required if an abscess develops
73
Q

Identify possible complications of epididymitis and orchitis

A
  • Pain
  • Abscess
  • Fournier’s gangrene (if the infection is left untreated and spreads)
  • Mumps orchitis could cause testicular atrophy and fertility issues
74
Q

Summarise the prognosis for patients with epididymitis and orchitis

A
  • GOOD if treated
  • May take up to 2 months for the swelling to resolve
75
Q

Urinary Tract Infection

Define urinary tract infection

A
  • The presence of a pure growth of > 105 organisms per mL of fresh MSU
  • Sub-Classification
    • Lower UTI - affecting the urethra (urethritis), bladder (cystitis) or prostate (prostatitis)
    • Upper UTI - affecting the renal pelvis (pyelonephritis)
  • NOTE: the laboratory classification mentioned above isn’t a complete necessity for the diagnosis of UTI - 1/3 women with symptoms of UTI will have negative MSU
  • Other Classification
    • Uncomplicated UTI - normal renal tract and function
    • Complicated UTI - abnormal renal/genitourinary tract, voiding difficulty/obstruction, reduced renal function, impaired host defences, virulent organism (e.g. S. aureus)
76
Q

Explain the aetiology/risk factors of urinary tract infection

A
  • MOST UTIs are caused by Escherichia coli
  • Other causative organisms:
    • Staphylococcus saprophyticus
    • Proteus mirabilis
    • Enterococci
  • Atypical organisms that can cause UTI (usually in immunocompromised individuals):
    • Klebsiella
    • Candida albicans
    • Pseudomonas aeruginosa
  • Risk Factors
    • FEMALE
    • Sexual intercourse
    • Exposure to spermicide
    • Pregnancy
    • Menopause
    • Immunosuppression
    • Catheterisation
    • Urinary tract obstruction
    • Urinary tract malformation
77
Q

Recognise the presenting symptoms of urinary tract infections

A
  • Cystitis
    • Frequency
    • Urgency
    • Dysuria
    • Haematuria
    • Suprapubic pain
  • Prostatitis
    • Flu-like symptoms
    • Low backache
    • Few urinary symptoms
    • Swollen or tender prostate on PR
  • Acute Pyelonephritis
    • High fever
    • Rigors
    • Vomiting
    • Loin pain and tenderness
    • Oliguria (if AKI)
78
Q

Summarise the epidemiology of urinary tract infections

A
  • VERY COMMON
  • 1-3% of GP consultations
  • The majority of women will have a UTI in their lifetime
  • MUCH more common in FEMALES
80
Q

Recognise the signs of urinary tract infection on physical examination

A
  • Fever
  • Abdominal or loin tenderness
  • Foul-smelling urine
  • Distended bladder (occasionally)
  • Enlarged prostate (if prostatitis)
81
Q

Identify appropriate investigations for urinary tract infection

A
  • Urine Dipstick
    • Positive leucocyte esterase and nitrites
  • Urine Microscopy
    • Presence of leucocytes indicates infection
  • Urine Culture
    • To exclude diagnosis or if the patient failed to respond to empirical antibiotics
  • Ultrasound
    • Rule out obstruction
  • Bloods
    • FBC
    • U&Es - check renal function
    • CRP
    • Blood cultures - if systemically unwell and risk of urosepsis
82
Q

Generate a management plan for urinary tract infection

A
  • Empirical treatment of uncomplicated UTI: TRIMETHOPRIN or NITROFURANTOIN
    • Treat for 3-6 days
    • NOTE: men with UTI may need a longer course of antibiotics
  • Alternative Treatments: Co-amoxiclav or Cefalexin
  • Prophylactic antibiotics may be used in certain circumstances (e.g. recurrent cystitis associated with sexual intercourse)
83
Q

Identify possible complications of urinary tract infection

A
  • Ascending infection can lead to:
    • Pyelonephritis
    • Perinephric and intrarenal abscess
    • Hydronephrosis or pyonephrosis
    • AKI
    • Sepsis
  • Prostatic involvement (e.g. prostatitis) in men with UTIs is common

Summarise the prognosis for urinary tract infection

  • GOOD prognosis with appropriate treatment
84
Q

Amyloidosis

Define amyloidosis

A
  • Heterogenous group of diseases characterised by extracellular deposition of amyloid fibrils
85
Q

Explain the aetiology/risk factors of amyloidosis

A
  • Amyloid fibrils are polymers of low-molecular-weight subunit proteins
  • These are derived from proteins that undergo conformational changes to adopt an anti-parallel beta-pleated sheet configuration
  • Their deposition progressively disrupts the structure and function of normal tissue
  • Amyloidosis is classified according to the fibril subunit proteins
    • Type AA - serum amyloid A protein
    • Type AL - monoclonal immunoglobulin light chains
    • Type ATTR (familial amyloid polyneuropathy) - genetic-variant transthyretin
86
Q

Summarise the epidemiology of amyloidosis

A
  • AA - incidence of 1-5% amongst patients with chronic inflammatory diseases
  • AL - 300-600 cases in the UK per year
  • Hereditary Amyloidosis - accounts for 5% of patients with amyloidosis
87
Q

Recognise the presenting symptoms and signs of amyloidosis

A
  • Renal - proteinuria, nephrotic syndrome, renal failure
  • Cardiac - restrictive cardiomyopathy, heart failure, arrhythmia, angina
  • GI - macroglossia (characteristic of AL), hepatosplenomegaly, gut dysmotility, malabsorption, bleeding
  • Neurological - sensory and motor neuropathy, autonomic neuropathy, carpal tunnel syndrome
  • Skin - waxy skin and easy bruising, purpura around the eyes (characteristic of AL), plaques and nodules
  • Joints - painful asymmetrical large joints, enlargement of anterior shoulder
  • Haematological - bleeding tendency
89
Q

Identify appropriate investigations for amyloidosis

A
  • Tissue Biopsy
  • Urine - check for proteinuria, free immunoglobulin light chains (in AL)
  • Bloods
    • CRP/ESR
    • Rheumatoid factor
    • Immunoglobulin levels
    • Serum protein electrophoresis
    • LFTs
    • U&Es
  • SAP Scan - radiolabelled SAP will localise the deposits of amyloid
90
Q

Glomerulonephritis

Define glomerulonephritis

A
  • An immunologically mediated inflammation of the renal glomeruli
91
Q

Explain the aetiology / risk factors of glomerulonephritis

A
  • There are loads of different types of glomerulonephritis with different aetiologies
  • Some types are caused by the deposition of antigen-antibody complexes in the glomeruli
  • This leads to inflammation and activation of complement and coagulation cascades
  • The immune complexes may form within the glomerulus (more common) or be deposited from the circulation
  • The antigens to which the antibodies are produced are UNKNOWN but may be associated with:
    • Bacteria (e.g. Streptococcus viridans, Staphylococci)
    • Viruses (e.g. HBV, HCB, measles, mumps, EBV)
    • Protozoal (e.g. Plasmodium malariae, schistosomiasis)
    • Inflammatory/Systemic diseases (e.g. SLE, vasculitis, cryoglobulinaemia)
    • Drugs (e.g. gold, penicillinamine)
    • Tumour
  • Classification is based on the site of nephron pathology and its distribution
    • Minimal-change Glomerulonephritis
      • Light microscopy - minimal change
      • Electron microscopy - loss of epithelial foot process
    • Membranous Glomerulonephritis
      • Thickening of glomerular basement membrane (GBM) from immune complex deposition
      • Associated with Goodpasture’s Syndrome
    • Membranoproliferative Glomerulonephritis (MPGN)
      • Thickening of GBM
      • Mesangial cell proliferation and interdeposition
    • Focal segmental glomerulosclerosis
      • Glomerular scarring
      • Associated with HIV
    • Focal segmental proliferative glomerulonephritis
      • Mesangial and endothelial cell proliferation
      • Focal = involvement of some glomeruli
      • Segmental = involvement of parts of individual glomeruli
    • Diffuse proliferative glomerulonephritis
      • Same as above but affects ALL glomeruli
    • IgA Nephropathy
      • Mesangial cell proliferation
      • Mesangial IgA and C3 deposits
    • Crescentic Glomerulonephritis
      • Crescent formation by macrophages and epithelial cells, which fills up Bowman’s space
    • Focal Segmental Necrotising Glomerulonephritis
      • Peripheral capillary loop necrosis (occurs in granulomatosis with polyangiitis, microscopy polyarteritis and other vasculitides)
      • Often evolves into crescentic glomerulonephritis

NOTE: cryoglobulins are immunoglobulins that precipitate in the cold

92
Q

Summarise the epidemiology of glomerulonephritis

A
  • Accounts for 25% of the cases of chronic renal failure
93
Q

Recognise the presenting symptoms of glomerulonephritis

A
  • Haematuria
  • Subcutaneous oedema
  • Polyuria or oliguria
  • History of recent infection
  • Symptoms of uraemia or renal failure (acute and chronic)
94
Q

Recognise the signs of glomerulonephritis on physical examination

A
  • Hypertension
  • Proteinuria
  • Haematuria (especially in IgA nephropathy)
  • Renal failure
  • Nephrotic syndrome - consists of a TRIAD of:
    • Proteinuria > 3.5 g/24 hrs
    • Low serum albumin < 24 g/L
    • Oedema
    • NOTE: due to the hypoalbuminaema, the liver tries to compensate and increases production of lipids, causing hyperlipidaemia
  • Nephritic syndrome (TRIAD: hypertension + proteinuria + haematuria)
    • Syndrome comprising of signs of nephritis
    • Pores in the podocytes are large enough to allow protein AND red blood cells to pass into the urine
    • MAIN FEATURE: Haematuria
      • This is in contrast to nephrotic syndrome, which is mainly concerned with proteinuria
    • There may also be red cell casts in the urine - indicative of glomerular damage
    • Other features:
      • Proteinuria
      • Hypertension
      • Low urine output (due to decreased renal function)
    • NOTE: in nephrotic syndrome, only PROTEINS are moving into the urine
95
Q

Identify appropriate investigations for glomerulonephritis

A
  • Bloods
    • FBC
    • U&Es + creatinine
    • LFTs (check albumin)
    • Lipid profile
    • Complement studies
    • Antibodies:
      • ANA
      • Anti-dsDNA
      • ANCA
      • Anti-GBM antibody
      • Cryoglobulins
  • Urine
    • Microscopy - check for red cell casts
    • 24 hr collection: creatinine clearance and protein
  • Imaging
    • Renal tract ultrasound to exclude other pathology (e.g. obstruction)
  • Renal Biopsy
    • For microscopy
  • Investigations for associated conditions (e.g. HBV, HCV and HIV serology)
96
Q

Hydrocoele

Define hydrocoele

A
  • The excessive collection of serous fluid within the tunica vaginalis
97
Q

Explain the aetiology/risk factors of hydrocoeles

A
  • Congenital
  • Idiopathic
  • Tumour
  • Infection
  • Trauma
  • Underlying testicular torsion
  • Testicular appendage
  • Risk Factors/Associations
    • Indirect inguinal hernias in children
    • Epididymo-orchitis
    • Filariasis (in countries of high prevalence)
98
Q

Summarise the epidemiology of hydrocoeles

A
  • VERY COMMON in CHILDREN in the first year of life
  • Common in older men
99
Q

Recognise the presenting symptoms of hydrocoeles

A
  • Scrotal swelling
  • Usually ASYMPTOMATIC
  • Patients may complain of pain or urinary symptoms due to the underlying cause
100
Q

Recognise the signs of hydrocoeles on physical examination

A
  • Scrotal swelling
  • It is possible to get above the swelling
  • Transilluminates
  • Difficult to separate the swelling from the testicle
101
Q

Identify appropriate investigations for hydrocoeles

A
  • Ultrasound - exclude tumour
  • Urine - dipstick and MSU for infection
  • Blood - markers of testicular tumours:
    • a-fetoprotein
    • b-HCG
    • Lactate dehydrogenase
102
Q

Nephrotic Syndrome

Define nephrotic syndrome

A
  • Nephrotic syndrome is characterised by a triad of:
    • Proteinuria (> 3 g/24 hr)
    • Hypoalbuminaemia (< 30 g/L)
    • Oedema
    • Hypercholesterolaemia is also a common feature
103
Q

Explain the aetiology / risk factors of nephrotic syndrome

A
  • Most commonly caused by: minimal change glomerulonephritis in children
  • However, ALL forms of glomerulonephritis can cause nephrotic syndrome
  • Other causes:
    • Diabetes mellitus
    • Sickle cell disease
    • Amyloidosis
    • Malignancies (lung and GI adenocarcinomas)
    • Drugs (e.g. NSAIDs)
    • Alport’s syndrome
    • HIV
104
Q

Summarise the epidemiology of nephrotic syndrome

A
  • 90% of nephrotic syndrome in CHILDREN is due to minimal change glomerulonephritis
  • Most common cause of nephrotic syndrome in ADULTS:
    • Diabetes mellitus
    • Membranous glomerulonephritis
105
Q

Recognise the presenting symptoms of nephrotic syndrome

A
  • Family history of atopy (in those with minimal change glomerulonephritis)
  • Family history of renal disease
  • Swelling of face, abdomen, limbs, genitalia (due to hypoalbuminaemia)
  • Symptoms of the underlying cause (e.g. SLE)
  • Symptoms of complications
106
Q

Recognise the signs of nephrotic syndrome on physical examination

A
  • Oedema: periorbital, peripheral, genital
  • Ascites: fluid thrill, shifting dullness
107
Q

Identify appropriate investigations for nephrotic syndrome

A
  • Bloods
    • FBC
    • U&E
    • LFTs (low albumin)
    • ESR/CRP
    • Glucose
    • Lipid profile (check for secondary hyperlipidaemia)
    • Immunoglobulins
    • Complement
  • Tests to identify the cause
    • SLE - ANA, anti-dsDNA antibodies
    • Infections:
      • Group A b-haemolytic streptococcal infection (ASO titre)
      • HBV infection (serology)
      • Plasmodium malariae (blood film)
    • Goodpasture’s Syndrome - anti-glomerular basement antibodies
    • Vasculitides - polyangiitis with granulomatosis, microscopic polyarteritis (check ANCA)
  • Urine
    • Urinalysis (check protein and blood)
    • MC&S
    • 24 hr collection (calculate creatinine clearance and 24 hr protein excretion)
  • Renal Ultrasound
    • Exclude other causes (e.g. reflux nephropathy)
  • Renal Biopsy
  • Other imaging: Doppler ultrasound, renal angiogram, CT or MRI (if renal vein thrombosis suspected)
108
Q

Polycystic Kidney Disease

Define polycystic kidney disease

A
  • Autosomal dominant inherited disorder characterised by the development of multiple renal cysts that gradually expand and replace normal kidney substance, variably associated with extrarenal (liver and cardiovascular) abnormalities
109
Q

Explain the aetiology / risk factors of polycystic kidney disease

A
  • 85% caused by mutations in PKD1 on chromosome 16
    • This is a membrane-bound multidomain protein involved in cell-cell and cell-matrix interactions
  • 15% caused by mutations of PKD2 on chromosome 4
  • Pathophysiology
    • Proliferative/hyperplastic abnormality of the tubular epithelium
    • Early on, the cysts are connected to the tubules from which they arise and the fluid content is glomerular filtrate
    • When cyst diameter >2 mm, they detach from the tubule and the fluid content is derived from secretion of the lining epithelium
    • With time, the cysts enlarge and cause progressive damage to adjacent functioning nephrons
110
Q

Summarise the epidemiology of polycystic kidney disease

A
  • MOST COMMON inherited kidney disorder
  • Responsible for 10% of end-stage renal failure
111
Q

Recognise the presenting symptoms of polycystic kidney disease

A
  • Present at 30-40 yrs
  • 20% have no family history
  • May be asymptomatic
  • Flank Pain - may result from cyst enlargement/bleeding, stone, blood clot migration, infection
  • Haematuria
  • Hypertension
  • Associated with berry aneurysms and may present with subarachnoid haemorrhage
112
Q

Recognise the signs of polycystic kidney disease on physical examination

A
  • Abdominal distension
  • Enlarged cystic kidneys
  • Palpable liver
  • Hypertension
  • Signs of chronic renal failure (at late stage)
  • Signs of associated AAA or aortic valve disease
113
Q

Identify appropriate investigations for polycystic kidney disease

A
  • US or CT
    • Will show multiple cysts bilaterally in enlarged kidneys
    • Liver cysts may also be seen
114
Q

Renal Artery Stenosis

Define renal artery stenosis

  • Stenosis of the renal artery

Explain the aetiology / risk factors of renal artery stenosis

A
  • Atherosclerosis (older patients) - widespread aortic disease involving the renal artery ostia
  • Fibromuscular Dysplasia (younger patients)
    • Unknown aetiology
    • May be associated with collagen disorders, neurofibromatosis and Takayasu’s arteritis
    • May be associated with micro-aneurysms in the mid and distal renal arteries (resembling a string of beads on angiography)
  • Pathogenesis/Pathophysiology
    • Renal hypoperfusion (due to the stenosis) stimulates the renin-angiotensin system leading to increased angiotensin II and increased aldosterone
    • This leads to increased blood pressure
    • The high blood pressure leads to fibrosis, glomerulosclerosis and renal failure
115
Q

Summarise the epidemiology of renal artery stenosis

A
  • Prevalence unknown
  • Accounts for 1-5% of all hypertension
  • Fibromuscular dysplasia occurs mainly in women with hypertension < 45 yrs
116
Q

Recognise the presenting symptoms of renal artery stenosis

A
  • History of hypertension in < 50 yrs
  • Hypertension refractory to treatment
  • Accelerated hypertension and renal deterioration on starting ACE inhibitors
  • History of flash pulmonary oedema
  • IMPORTANT: ACE INHIBITORS ARE BAD IN RENAL ARTERY STENOSIS
117
Q

Recognise the signs of renal artery stenosis on physical examination

A
  • Hypertension
  • Signs of renal failure in advanced bilateral disease
  • Renal artery bruits
118
Q

Identify appropriate investigations for renal artery stenosis

A
  • Non-Invasive
    • Duplex ultrasound
    • Ultrasound measurement of kidney size
  • CT Angiogram or MR Angiography: risk of contrast nephrotoxicity
  • Digital Subtraction Angiography = GOLD STANDARD
  • Renal Scintigraphy
    • Uses radio-agent that is either excreted by glomerular filtration or by the tubules
    • Addition of an ACE inhibitor causes delayed clearance by the affected kidney (may not be useful in bilateral renal artery stenosis)
119
Q

Testicular Torsion

Define testicular torsion

A
  • A SURGICAL EMERGENCY. Twisting or torsion of the spermatic cord results, initially, in venous outflow obstruction from the testicle, progressing to arterial occlusion and testicular infarction if not corrected.
120
Q

Explain the aetiology/risk factors of testicular torsion

A
  • Intravaginal (MOST COMMON)
    • The spermatic cord twists within the tunica vaginalis
  • Extravaginal (usually in neonates)
    • The entire testis and tunica vaginalis twist in a vertical axis on the spermatic cord
    • Due to incomplete fixation of the gubernaculum to the scrotal wall allowing free rotation
  • Risk Factors
    • Imperfectly descended testes
    • High investment of the tunica vaginalis
121
Q

Summarise the epidemiology of testicular torsion

A
  • Most common cause of acute scrotal pain in 10-18 yr olds
122
Q

Recognise the presenting symptoms of testicular torsion

A
  • Sudden-onset severe hemiscrotal pain
  • Abdominal pain
  • Nausea and vomiting
123
Q

Recognise the signs of testicular torsion on physical examination

A
  • Swollen, erythematous scrotum on the affected side
  • Swollen testicle will lie slightly higher than the unaffected one
  • Testicle might lie horizontal
  • Thickened cord
  • Testicular Appendix
    • There may be a visible necrotic lesion on transillumination
  • Differential Diagnosis
    • Epididymo-orchitis
    • Incarcerated inguinal hernia
124
Q

Identify appropriate investigations for testicular torsion

A
  • Doppler/Duplex Imaging of the Testes
    • Do NOT delay surgery
    • Arterial inflow
      • REDUCED in testicular torsion
      • INCREASED in epididymo-orchitis
125
Q

Generate a management plan for testicular torsion

A
  • Exploration of the scrotum within 6 hrs of onset of symptoms
  • After the testicle is twisted back into place, a bilateral orchidopexy is performed
  • This involves suturing the testicle to the scrotal tissue to prevent recurrence
  • If the testicle is necrotic, orchidectomy may be performed
126
Q

Identify possible complications of testicular torsion

A
  • Testicular infarction
  • Testicular atrophy
  • Infection
  • Impaired fertility (due to production of anti-sperm antibodies)
127
Q

Summarise the prognosis for patients with testicular torsion

A
  • From the onset of torsion, a testicle may only survive 4-6 hrs
  • With prompt surgical intervention, most testicles are salvaged
128
Q

Urinary Tract Calculi

Define urinary tract calculi

A
  • Crystal deposition within the urinary tract. Also known as nephrolithiasis.
  • Types of Stone:
    • Calcium oxalate - MOST COMMON
    • Struvite - quite common
    • Urate - 5%
    • Cysteine - 2%
129
Q

Explain the aetiology/risk factors of urinary tract calculi

A
  • Many cases are IDIOPATHIC
  • Metabolic Causes
    • Hypercalciuria
    • Hyperuricaemia
    • Hypercystinuria
    • Hyperoxaluria
  • Infection
    • Hyperuricaemia
  • Drugs
    • Indinavir
  • RISK FACTORS:
    • Low fluid intake
    • Structural urinary tract abnormalities (e.g. horseshoe kidney)
130
Q

Summarise the epidemiology of urinary tract calculi

A
  • COMMON
  • 2-3% of general population
  • 3 x more common in MALES
  • Age group affected: 20-50 yrs
  • Bladder stones more common in developing countries
  • Upper urinary tract stones more common in industrialised countries
131
Q

Recognise the presenting symptoms of urinary tract calculi

A
  • Often ASYMPTOMATIC
  • SEVERE loin to groin pain
  • Nausea and vomiting
  • Urinary urgency, frequency or retention
  • Haematuria
132
Q

Recognise the signs of urinary tract calculi on physical examination

A
  • Loin to lower abdominal tenderness
  • NO signs of peritonism
  • Leaking AAA is the main differential to consider in older men
  • Signs of systemic sepsis if there is an obstruction and infection above the stone
133
Q

Identify appropriate investigations for urinary tract calculi

A
  • Bloods
    • FBC - high WCC if infection
    • U&Es - check renal function
    • Calcium
    • Urate
    • Phosphate
  • Urine
    • Dipstick - haematuria is common
    • MC&S
  • X-Ray KUB
    • 80% of kidney stones are radio-opaque
  • Intravenous Urography (IVU)
    • Allows visualisation of the kidneys and ureters
  • Ultrasound
    • May show hydronephrosis and hydroureter
  • Non-enhanced Spiral CT
    • Can also be used to image stones
  • Isotope Radiography
    • Used to assess kidney function
134
Q

Generate a management plan for urinary tract calculi

A
  • ACUTE PRESENTATION
    • Analgesia
    • Bed rest
    • Fluid replacement
    • Urine collection to try and retrieve any stone that has passed
      • NOTE: most stones < 5 mm will pass spontaneously
    • An obstructed, infected kidney is an EMERGENCY and should be treated as soon as possible to relieve the obstruction (e.g. by placing a percutaneous nephrostomy)
  • REMOVAL OF CALCULI
    • Urethroscopy
      • A scope is passed into the bladder and up the ureter to visualise the stone
      • It can then be removed by a basket or broken up with a laser
      • If the stone cannot be removed, a JJ stent should be placed to allow urine drainage
    • Extracorporeal Shock-Wave Lithotripsy (ESWL)
      • Non-invasive
      • An electromagnetic shockwave is focused onto the calculus to break it up into smaller fragments that can pass spontaneously
    • Percutaneous Nephrolithotomy (PCNL)
      • Performed for large, complex stones (e.g. staghorn calculi)
      • After making a nephrostomy tract, a nephroscope is inserted, which allows disintegration and removal of stones
  • TREATMENT OF CAUSE
    • Depends on the cause (e.g. parathyroidectomy if hypercalcaemia due to hyperparathyroidism, allopurinol if hyperuricaemia)
  • ADVICE
    • Increase oral fluid intake
135
Q

Identify possible complications of urinary tract calculi

A
  • Of Stones
    • Infection (PYELONEPHRITIS)
    • Septicaemia
    • Urinary retention
  • Of Ureteroscopy
    • Perforation
    • False passage
  • Of Lithotripsy
    • Pain
    • Haematuria
136
Q

Summarise the prognosis for patients with urinary tract calculi

A
  • GOOD
  • However, infection of the calculus could lead to irreversible renal scarring
  • Recurrence of about 50% over 5 yrs
137
Q

Varicocoele

Define varicocoele

A
  • DEFINITION: dilated veins of the pampiniform plexus forming a scrotal mass.
138
Q

Explain the aetiology/risk factors of varicocoele

A
  • More common on the LEFT (80-90%) because of:
    • The angle at which the left testicular vein meets the left renal vein
    • Lack of effective valves between the left testicular vein and left renal vein
    • Increased reflux from compression of the renal vein (between the superior mesenteric artery and the aorta)
  • Due to venous incompetence (sort of like varicose veins)
139
Q

Summarise the epidemiology of varicocoele

A
  • Unusual in boys under 10 yrs old
  • Incidence increases after puberty
  • Incidence: 15% in general population
  • Associated with infertility
140
Q

Recognise the presenting symptoms of varicocoele

A
  • Usually ASYMPATOMATIC
    • Only 2-10% have symptoms
  • Scrotum feels like a bag of worms
  • Scrotal heaviness
  • Incidental finding at examination
141
Q

Recognise the signs of varicocoele on physical examination

A
  • Patient must be STANDING for examination
  • The side of the scrotum with the varicocoele will hang lower
  • The swelling may reduce when lying down
  • Valsalva manouevre whilst standing will increase dilatation
  • Cough impulse
142
Q

Identify appropriate investigations for varicocoele

A
  • Sperm count - done as part of fertility investigation
  • Colour Doppler scan

Year 3 Medicine lectures (5 decks)

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