Urology and Renal Medicine Flashcards
What is chronic kidney disease?
Abnormalities in kidney structure or function present for ≥3 months (GFR <60 mL/minute/1.73 m²) or other markers of kidney damage, e.g. proteinuria
What are the key diagnostic factors of chronic kidney disease?
Patients typically asymptomatic until stage 4 or 5 CKD
Fatigue
Oedema (salt and water retention)
Nausea with or without vomiting (accumulation of urea)
Pruritus
Restless legs
Anorexia
Foamy cola-coloured urine
Rashes (ecchymosis and purpura)
Dyspnoea and orthopnoea
Seizures
Hypertensive retinopathy
Apart from GFR, what other evidence suggests CKD?
Persistent microalbuminuria
Persistent proteinuria
Persistent haematuria (after exclusion of other causes, e.g. urological disease)
Structural abnormalities of kidney seen on imaging (e.g. polycystic kidney disease, reflux nephropathy)
Biopsy-proven chronic glomerulonephritis
What are the risk factors for CKD?
Diabetes mellitus
Hypertension
Age >50 years
Smoking
Obesity
Black or Hispanic ethnicity
Family history
Immune disorders, e.g. SLE, RA
Male sex
Long term use of NSAIDs
How is CKD investigated?
U&Es
eGFR
Urinalysis (haematuria and proteinuria)
Urinary albumin
Renal ultrasound (small kidneys, polycystic kidneys)
Kidney biopsy
How is GFR category G1-G2 w/o uraemia treated?
ACEi or ARB (ramipril or losartan) - CCB is second line
Dapagliflozin (SGLT2)
Statin (simvastatin)
Consider atenolol, amlodipine, spiranolactone
How is GFR category G5 or with uraemia treated?
1st line is dialysis
2nd line is kidney transplant
What are the diagnostic criteria for AKI?
Rise in creatinine of ≥ 25 micromol/L in 48 hours
Rise in creatinine of ≥ 50% in 7 days
Urine output of < 0.5ml/kg/hour for > 6 hours
What are the risk factors for AKI?
CKD
Heart failure
Diabetes
Liver disease
>65 years
Cognitive impairment
Nephrotoxic medications, e.g. NSAIDs or ACEi
Use of contrast mediums, e.g. CT scans
What are pre-renal causes of AKI?
Inadequate blood supply to kidneys reducing the filtration of blood, i.e. due to:
Dehydration
Hypotension (shock)
Heart failure
What are some renal causes of AKI?
Intrinsic disease in kidney reduces filtration of blood
Glomerulonephritis
Interstitial nephritis
Acute tubular necrosis
What are some post-renal causes of AKI?
Obstruction to the outflow of urine from the kidney, causing back-pressure into the kidney and reduced kidney function
Kidney stones
Masses such as cancer in the abdomen or pelvis
Ureter or uretral strictures
Enlarged prostate or prostate cancer
What are the symptoms of AKI?
Nausea or vomiting
Diarrhoea
Dehydration
Decreased urine output
Confusion
Drowsiness
Can often be asymptomatic
How is AKI investigated?
Urea and creatinine
Serum potassium (hyperkalaemia is complication of AKI)
Urinalysis
Ultrasound of urinary tract to look for obstruction
How is AKI managed?
Treat underlying cause
Fluid rehydration with IV fluids in pre-renal cause
Stop nephrotoxic medications, e.g. ACEi or NSAIDs
Relieve obstruction in post-renal AKI, e.g. with catheter
What are the features of nephrotic syndrome?
Low serum albumin (<25g/L)
High urine protein content (foamy urine)
Oedema
Deranged lipid profile (high cholesterol, triglycerides, LDLs)
High blood pressure
Hyper-coagulability
MOST COMMONLY SEEN IN 2-5 YEAR OLDS
What are the causes of nephrotic syndrome?
Minimal change disease (most common cause)
Intrinsic kidney disease (membranoproliferative glomerulonephritis, focal segmental glomerulosclerosis)
Secondary to underlying illness (diabetes, henoch schonlein purpura, infection - HIV, hepatitis, malaria)
How is minimal change disease diagnosed?
Urinalysis (small molecular weight proteins and hyaline casts)
Serum albumin (low)
Serum lipid profile (high cholesterol)
Urine dipstick (proteinuria)
Renal biopsy (for steroid-resistant patients)
How is nephrotic syndrome managed?
High dose steroids (prednisolone) - given for 4 weeks and gradually weaned over 8 weeks
ACEi (ramipril) and immunosuppressants (cyclosporine, rituximab) in steroid-resistant children
Low salt diet
Diuretics to treat oedema (furosemide)
Albumin infusions in severe hypoalbuminaemia
Antibiotic prophylaxis in severe cases
Prophylactic anticoagulation (low molecular weight heparin or warfarin)
What are complications of nephrotic syndrome?
Hypovolaemia
Thrombosis (anti-clotting factors lost in kidneys, liver produces pro-thrombotic factors in response to low albumin)
Infections (kidneys leak immunoglobulins)
Acute or chronic renal failure
Relapse
What is testicular torsion?
Twisting of the spermatic cord resulting in constriction of vascular supply and ischemia of testicular tissue
What are the risk factors for testicular torsion?
Age <25 years
Bell clapper deformity (allows testicles to rotate freely within tunica vaginalis)
What are the symptoms of testicular torsion?
Acute onset of unilateral testicular pain - trigger such as playing sports
Abdominal pain and vomiting
Firm swollen testicle (oedema)
Elevated testicle - no pain relief upon elevation of scrotum
Absent cremasteric reflex
Abnormal testicular lie (often horizontal)
Rotation, so that epididymis is not in normal posterior position
USUALLY TEENAGE BOYS
How is testicular torsion investigated?
Scrotal ultrasound (whirlpool sign) - will delay treatment, but confirms diagnosis
Surgical exploration is first line
How is testicular torsion treated?
Bilateral orchiopexy (correcting the position of the testicles and fixing them in place)
Orchidectomy (removing the testicle) if the surgery is delayed or there is necrosis
What are the symptoms of benign prostatic hyperplasia?
Storage symptoms: frequency, urgency, nocturia
Voiding symptoms: weak stream, hesitancy, intermittency, straining, incomplete emptying, post-void dribbling
What are the risk factors for BPH?
Age >50 years
Family history
How is BPH investigated?
DRE (assess size, shape and characteristics of prostate)
Urinalysis (normal in uncomplicated BPH, may show UTI, haematuria suggests bladder cancer)
PSA (false positives and negatives high)
Urinary frequency volume chart (show fluid intake and output)
What are some causes of raised PSA?
Prostate cancer
BPH
Prostatitis
UTIs
Vigorous exercise (particularly cycling)
Recent ejaculation or prostate stimulation
How is BPH treated?
Alpha-blockers (tamsulosin) - relaxes smooth muscle (symptom control)
5-alpha reductase inhibitors (finasteride) - reduces size of prostate
Transurethral resection of prostate (TURP)
Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
Holmium laser enucleation of the prostate (HoLEP)
Open prostatectomy via an abdominal or perineal incision
What are the side effects of tamsulosin?
Postural hypotension
What are the side effects of finasteride?
Sexual dysfunction (decreased testosterone)
What are the symptoms of a lower UTI?
Dysuria (pain or burning when passing urine)
Suprapubic pain or tenderness
Increased frequency and urgency
Incontinence
Cloudy-looking urine
Confusion is commonly the only symptom in older patients
What are the symptoms of pyelonephritis?
Fever
Loin, suprapubic or back pain
Malaise
Vomiting
Loss of appetite
Haematuria
What are the risk factors for UTIs?
Sexual activity
Spermicide use
Post-menopause
Catheter
History of recurrent UTIs
How is UTI investigated?
Urine dipstick
Urine culture and sensitivity if nitrites and leukocytes present
What are the causative organisms of bacteria?
E. coli (most common)
Klebsiella pneumoniae
Enterococcus
Pseudomonas aeruginosa
How are simple UTIs managed?
Trimethoprim (avoided in first trimester of pregnancy and if mother on anti-epileptics)
Nitrofurantoin (avoided in third trimester of pregnancy)
How long are antibiotics given for UTIs?
3 days for simple UTI in women
5-10 days of antibiotics for women that are immunosuppressed, have abnormal anatomy or impaired kidney function
7 days of antibiotics for men, pregnant women or catheter related UTIs
How is pyelonephritis treated?
7-10 days of cefalexin OR co-amoxiclav OR trimethoprim
What are the risk factors for bladder cancer?
Tobacco exposure; MESOTHELIOMA
Male sex
Age >55 years
Exposure to chemical carcinogens - aromatic amines (dye and rubber); TRANSITIONAL CELL CARCINOMA
Pelvic radiation
Systemic chemotherapy
Schistosomiasis; SQUAMOUS CELL CARCINOMA
Family history
What are the symptoms of bladder cancer?
Painless haematuria (gross or microscopic)
Dysuria (painful urination)
Recurrent UTIs or lower urinary tract symptoms
How is bladder cancer investigated?
Urinalysis (haematuria present in 80% of patients) - 1st line
Cystoscopy and biopsy - gold standard
How is bladder cancer treated?
DEPENDENT ON DISEASE STAGING
Carcinoma in-situ: resection via TURBT
Muscle-invasive bladder cancer: radical cystectomy, ileal conduit formation/bladder reconstruction
Metastatic disease: chemotherapy (cisplatin-based regime)
What are the risk factors for epididymitis?
Multiple sexual partners - most commonly caused by sexually transmitted pathogens
Bladder outflow obstruction
Cystopic procedures and catheterisation
Immunosuppression
Age >19 years
How does epididymitis present?
Unilateral, gradual onset (minutes-hours)
Testicular pain and swelling
Tenderness on palpation
Urethral discharge (gonorrhoea or chlamydia)
Systemic symptoms, e.g. fever, sepsis
How is epididymitis investigated?
in younger adults, test for STIs with NAAT
in older adults, midstream sample of urine
surgical exploration if testicular torsion not excluded
What organisms commonly cause epidymitis?
Age <35 years: Chlamydia trachomatis, Neisseria gonorrhoea
Age >35 years: E. coli, Klebsiella
How is epididymitis managed?
Conservative: bed rest, scrotal elevation
Medical: analgesia, antibiotics
What antibiotics are given for enteric epididymitis?
Ofloxacin for 14 days
Levofloxacin for 10 days
Co-amoxiclav for 10 days (where quinolones are contraindicated)
What antibiotics are given for sexually transmitted epididymitis?
Intramuscular ceftriaxone (single dose)
Doxycycline
Ofloxacin
What are the types of kidney stones?
Calcium oxolate (most common)
Calcium phosphate
Uric acid
Struvite (associated with infection, produced by bacteria)
Cystine (semi-opaque, ground glass appearance)
Xanthine (radio-lucent)
What are the symptoms of kidney stones?
May be asymptomatic until they get stuck in the ureters
Renal colic (unilateral colicky loin to groin pain)
Haematuria
Nausea or vomiting
Reduced urine output
Symptoms of sepsis, if infection is present
How are kidney stones investigated?
Urine dipstick (haematuria, excludes infection)
U&Es (hypercalcaemia as cause?)
Non-contrast CT KUB
Renal ultrasound in pregnant women and children
What are some causes of hypercalcaemia?
Calcium supplementation
Hyperparathyroidism
Cancer
What are the complications of kidney stones?
Obstruction leading to acute kidney injury
Infection with obstructive pyelonephritis
How are kidney stones treated?
NSAIDs (IM diclofenac)
Antiemetics (metoclopramide)
Antibiotics if infection present
Tamsulosin (alpha-blocker) - may aid passage of stones
Surgical intervention if stone >10mm
If there is ureteric obstruction with infection, surgical decompression
What surgical interventions are used for kidney stones?
Extracorporeal shock wave lithotripsy (ESWL) - stone <2cm in aggregate
Ureteroscopy - stone <2cm in pregnant females
Percutaneous nephrolithotomy (PCNL) - complex renal calculi and staghorn calculi
Open surgery
What are the risk factors for prostate cancer?
Increasing age
Obesity
Afro-Caribbean ethnicity
FHx
What is the most common form of prostate cancer?
Adenocarcinoma
What are the symptoms of prostate cancer?
May be asymptomatic
Lower urinary tract symptoms: hesitancy, urinary retention, weak flow, terminal dribbling
Haematuria
Erectile dysfunction
Weight loss, back pain
How is prostate cancer investigated?
DRE: hard, asymmetrical, craggy, irregular prostate
Multiparametric MRI (1st line)
Prostate biopsy - transrectaul ultrasound-guided biopsy (TRUS) or transperineal biopsy
PSA (can be falsely raised)
How is prostate cancer assessed?
Gleason score
6 is considered low risk
7 is intermediate risk (3 + 4 is lower risk than 4 + 3)
8 or above is deemed to be high risk
How is prostate cancer managed?
Low risk disease: active surveillance
Intermediate and high risk: radical prostatectomy or radiotherapy
Metastatic disease: anti-androgen therapy, e.g. Goserelin
What are the risk factors for testicular cancer?
Undescended testes
Male infertility
Family history
Increased height
What are the symptoms of testicular cancer?
Painless lump - non-tender, hard, irregular, non-fluctuant
Gynaecomastia
Hydrocoele
Will spread to para-aortic lymph nodes
How is testicular cancer investigated?
Scrotal ultrasound
Alpha-fetoprotein (raised in teratomas, not seminomas)
Beta-hCG (raised in both teratomas and seminomas) - only 10% of seminomas
LDH (non-specific tumour marker)
Staging CT
What are the side effects of GnRH agonists?
Can cause a paradoxical increase in prostate cancer symptoms - inital rise in testosterone due to overstimulation of LH
Therefore, anti-androgen is given alongside
How is testicular cancer managed?
Surgery (radical orchidectomy)
Chemotherapy
Radiotherapy
Sperm banking
what are the complications of TURP?
TURP syndrome: mental confusion, vomiting, hypertension and bradycardia
urethral stricture/UTI
retrograde ejaculation
perforation of the prostate
what are the main complications of urethral bladder catheterization?
UTI (particularly Proteus mirabilis)
urethral trauma, inc. creation of false passage
urethral scarring and stricture
bladder perforation
what are the examination findings of a varicocoele?
throbbing/dull pain on standing
dragging sensation
subfertility
scrotal mass - feels like a ‘bag of worms’
more prominent on standing, disappears when lying down - if not, ?retroperitoneal tumour
