Urology and Renal conditions Flashcards

Question

**Recognise the presenting symptoms of bladder cancer**

Answer 1

* Painless macroscopic haematuria * Irritative/storage symptoms * Frequency * Urgency * Nocturia * Recurrent UTIs * Rarely: ureteral obstruction

Answer 2

* Often NO SIGNS * Bimanual examination may be performed as part of disease staging

Answer 3

* **Cystoscopy** - allows visualisation, biopsy or removal * Ultrasound * Intravenous urography * CT/MRI for staging

Answer 4

* *Primary malignant neoplasm of the prostate gland*

Answer 5

* UNKNOWN * **Risk Factors** * Age * Afro-Caribbean * Family history * Dietary factors * Occupational exposure to cadmium

Answer 6

* COMMON * 2nd most common cause of male cancer deaths

Answer 7

* 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)

Answer 8

* Asymmetrical hard nodular prostate * Loss of midline sulcus

Answer 9

* **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

Answer 10

* 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**

Answer 11

* UNCOMMON * 3% of all adult malignancies * Peak incidence: 40-60 yrs

Answer 12

* 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**

Answer 13

* **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**

Answer 14

* *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

Answer 15

* **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)

Answer 16

* UNKNOWN * **Risk Factors** * Maldescended testes * Ectopic testes * Atrophic tests

Answer 17

* UNCOMMON * 1% of male malignancies * Common age of onset: 18-35 yrs

Answer 18

* Swelling or discomfort of the testes * Backache due to para-aortic lymph node enlargement * Lung metastases --\> SOB, haemoptysis

Answer 19

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

Answer 20

* **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**

Answer 21

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

Answer 22

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

Answer 23

* 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

Answer 24

* **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** * **F**requency * **U**rgency * **N**octuria * **D**ysuria * **H**esitancy * **I**ncomplete voiding * **P**oor stream * **S**mell/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

Answer 25

* **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_

Answer 26

* **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**

Answer 27

* **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 * **5****a****-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

Answer 28

* 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

Answer 29

* Mild symptoms are usually well controlled medically * Most patients get significant relief from surgery

Answer 30

* *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

Answer 31

* 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

Answer 32

* COMMON * Risk increases with age * Often associated with other diseases (e.g. cardiovascular disease)

Answer 33

* 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

Answer 34

* 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

Answer 35

* **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**

Answer 36

* *Inflammation of the epididymis or testes* * 60% of epididymitis is associated with orchitis * Most cases of orchitis are associated with epididymitis

Answer 37

* 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)

Answer 38

* COMMON * Affects _all_ age groups * Most commonly: 20-30 yrs

Answer 39

* Painful, swollen and tender testis or epididymis * NOTE: less acute onset than testicular torsion * Penile discharge * **IMPORTANT**: ask about _sexual history_

Answer 40

* Swollen and tender epididymis or testis * Scrotum may be erythematous and oedematous * Pyrexia * Walking will be painful * Eliciting a cremasteric reflex may be painful

Answer 41

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

Answer 42

* **Medical** * Antibiotics * **Surgical** * Exploration of testicles if testicular torsion _cannot_ be excluded clinically * Required if an abscess develops

Answer 43

* Pain * Abscess * Fournier's gangrene (if the infection is left untreated and spreads) * **Mumps orchitis** could cause testicular atrophy and fertility issues

Answer 44

* GOOD if treated * May take up to 2 months for the swelling to resolve

Answer 45

* *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*)

Answer 46

* 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

Answer 47

* **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)

Answer 48

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

Answer 49

* Fever * Abdominal or loin tenderness * Foul-smelling urine * Distended bladder (occasionally) * Enlarged prostate (if prostatitis)

Answer 50

* **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

Answer 51

* 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)

Answer 52

* 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

Answer 53

* *Heterogenous group of diseases characterised by **extracellular deposition of amyloid fibrils***

Answer 54

* 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

Answer 55

* **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

Answer 56

* **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

Answer 57

* **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

Answer 58

* *An _immunologically mediated_ inflammation of the renal glomeruli*

Answer 59

* 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_

Answer 60

* Accounts for 25% of the cases of chronic renal failure

Answer 61

* Haematuria * Subcutaneous oedema * Polyuria or oliguria * History of recent infection * Symptoms of **uraemia** or **renal failure** (acute and chronic)

Answer 62

* 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

Answer 63

* **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)

Answer 64

* *The excessive collection of serous fluid within the **tunica vaginalis***

Answer 65

* 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)

Answer 66

* VERY COMMON in **CHILDREN** in the _first year of life_ * Common in **older men**

Answer 67

* Scrotal swelling * Usually ASYMPTOMATIC * Patients may complain of _pain_ or _urinary symptoms_ due to the **underlying cause**

Answer 68

* Scrotal swelling * It is possible to get above the swelling * Transilluminates * Difficult to separate the swelling from the testicle

Answer 69

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

Answer 70

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

Answer 71

* 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

Answer 72

* 90% of nephrotic syndrome in _CHILDREN_ is due to **minimal change glomerulonephritis** * Most common cause of nephrotic syndrome in _ADULTS_: * Diabetes mellitus * Membranous glomerulonephritis

Answer 73

* 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

Answer 74

* Oedema: periorbital, peripheral, genital * Ascites: fluid thrill, shifting dullness

Answer 75

* **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)

Answer 76

* *_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*

Answer 77

* 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**

Answer 78

* MOST COMMON inherited kidney disorder * Responsible for **10%** of end-stage renal failure

Answer 79

* 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**

Answer 80

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

Answer 81

* **US or CT** * Will show multiple cysts bilaterally in _enlarged kidneys_ * Liver cysts may also be seen

Answer 82

* **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**

Answer 83

* Prevalence unknown * Accounts for 1-5% of all hypertension * Fibromuscular dysplasia occurs mainly in _women with hypertension \< 45 yrs_

Answer 84

* 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**

Answer 85

* Hypertension * Signs of renal failure in advanced bilateral disease * Renal artery bruits

Answer 86

* **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)

Answer 87

* *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.*

Answer 88

* **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

Answer 89

* Most common cause of _acute scrotal pain_ in 10-18 yr olds

Answer 90

* Sudden-onset severe hemiscrotal pain * Abdominal pain * Nausea and vomiting

Answer 91

* 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

Answer 92

* **Doppler/Duplex Imaging of the Testes** * Do _NOT_ delay surgery * Arterial inflow * REDUCED in testicular torsion * INCREASED in epididymo-orchitis

Answer 93

* 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

Answer 94

* Testicular infarction * Testicular atrophy * Infection * Impaired fertility (due to production of anti-sperm antibodies)

Answer 95

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

Answer 96

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

Answer 97

* 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)

Answer 98

* 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

Answer 99

* Often ASYMPTOMATIC * **SEVERE loin to groin pain** * Nausea and vomiting * Urinary urgency, frequency or retention * Haematuria

Answer 100

* 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

Answer 101

* **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

Answer 102

* **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

Answer 103

* **Of Stones** * Infection (**PYELONEPHRITIS**) * Septicaemia * Urinary retention * **Of Ureteroscopy** * Perforation * False passage * **Of Lithotripsy** * Pain * Haematuria

Answer 104

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

Answer 105

* DEFINITION: *dilated veins of the **pampiniform plexus** forming a scrotal mass.*

Answer 106

* 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)

Answer 107

* Unusual in boys under 10 yrs old * Incidence increases after puberty * Incidence: 15% in general population * Associated with infertility

Answer 108

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

Answer 109

* 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

Answer 110

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

Urology and Renal conditions Flashcards

(134 cards)