Urology - general Flashcards
1
Q
Define AKI
A
- Urine output is <0.5ml/kg/h for >6 consecutive hours
- Serum creatinine rises by >26.4 μmol/L within 48h
- Serum creatinine rises >1.5x from the reference value known to have occurred within one week/ 50% or greater serum creatinine rise in the preceding 7 days
- > 25% fall in eGFR in children + young people within the past 7 days
2
Q
Pre-renal causes of AKI
A
- Hypotension (intravascular volume loss or redistribution)
- Hypovolaemia (extracellular volume loss)- Reduced effective arterial volume
- HF, protein losing encephalopathy (decreased CO)
- Drugs
- ACEi, NSAIDs, ARB, diuretics
Interstitial nephritis (renal AKI)
- secondary to NSAIDs, chronic frusemide use
- caused by - infections, drugs, immune diseases e.g. SLE, lymphoma, tumour lysis syndrome following chemo
3
Q
Renal causes of AKI
A
- Tubular disease
- acute tubular necrosis (post-ischaemic. nephrotoxic)
- Glomerular disease
- Interstitial disease
4
Q
Palpable kidneys
A
- Polycystic kidney disease
- Hydronephrosis
5
Q
Renal angle tenderness
A
- Renal colic
- Pyelonephritis
- Any other pathology that stretches the renal capsule
6
Q
Classification of CKD (5)
A
eGFR (ml/min) >90 kidney damage with preserved GFR e.g. proteinuria
60-90 kidney damage with mild renal impairment
30-59 moderate renal impairment
15-29 severe renal impairment
<15 end-stage renal failure
Normal GFR is 90ml/min
7
Q
Normal Urea value
A
2.5-7.1 mmol/L
8
Q
Normal Creatinine value
A
79-118 μmol/L
9
Q
Nephrotic syndrome
A
- Proteinuria (>3.5/24h)
- Hypoalbuminaemia (<30g/L)
- Oedema(+hyperlipidaemia)
Increased risk of infection - loss of complement + Ig in urine
Hypercoaguable state - loss of ATIII, hypogammaglobulaemia
10
Q
Nephritic syndrome
A
- Haematuria (sometimes macroscopic) – MAIN FEATURE
- HTN
- Sub-nephrotic-range proteinuria
11
Q
Nephrotic range proteinuria
Commonest causes in Children Young adults Older people Diabetics
A
Children + young adults - minimal change glomerulonephritis
Young adults - FSGC (focal segmental glomerulosclerosis)
Older people - membranous nephropathy
Diabetics - diabetic nephropathy
12
Q
Places where a renal calculus can get suck
A
Staghorn calculus - in kidney, non-mobile, no pain, incidental finding
Pelviureteric junction
Ureteric stone - pelvic brim
Vesicoureteric junction
13
Q
Complications of kidneys stones
A
- Ureteric stricture
- Infection
- Acute/chronic pyelonephritis
- Renal failure
- Intrarenal/periephric abscess (renal mass with fluid level on US - pus discharges through the renal capsule in the perinephric fat)
- Xanthogranulomatus pyelonephritis
- Urine extravasation into pelvic cavity
14
Q
Patients with PKD are at risk of
A
SAH
15
Q
Complications of chronic urinary retention (8)
A
- UTI
- Incontinence
- Bladder Stones
- Hydroureters/hydronephorsis
- Renal failure
- Acute-on-chronic retention
- Bladder wall hypertrophy (trabeculation)
- Bladder wall outpouchings (diverticula)
16
Q
Conditions that can lead to acute renal failure (5)
A
- Wegener’s granulomatosis
- Goodpasture’s syndrome
- Thrombotic thrombocytopenic purpura (TTP) - pentad of TTP
Thrombocytopenia
Microangiopathic haemolytic anaemia (MAHA)
Fever
Renal failure
Neurological symptoms - HUS
- Myeloma
- Retroperitoneal fibrosis
17
Q
Which part of the prostate is affected in BPH (definition of BPH)
A
slowly progressive nodular hyperplasia of the TRANSITIONAL (periurethral) zone of the prostate gland
It’s a histological diagnosis
18
Q
What kind of cancers are prostate cancers?
A
malignant tumour of glandular origin situated in the prostate
most are adenocarcinomas arising in the PERIPHERAL zone of the prostate gland
19
Q
All testicular tumours display an abnormality on Chr
A
12
20
Q
Which testiular cells are the most vulnerable to ischaemia?
A
Germ cells
21
Q
Which testis gets twisted most commonly?
A
Left
22
Q
Direct vs indirect inguinal hernia
A
Direct
Superior and medial to pubic tubercle
Through the abdominal wall
Medial to deep inferior epigastric artery
Through Hesselbach’s triangle
Doesn’t usually extend into scrotum
Cough impulse - will expand outwards (through the defect in the posterior wall of the inguinal canal)
Lower risk of strangulation than indirect hernias
greater tendency for spontaneous reduction
Indirect
More common than direct
Superior and medial to pubic tubercle
Through the deep inguinal ring
Lateral to deep inferior epigastric artery
lateral to Hesselbach’s triangle
More likely to extend into scrotum
Cough impulse - will expand in an inferomedial direction (along the length of the inguinal canal)
Higher risk of strangulation than direct hernias
deep inferior epigastric artery lies medial to the deep inguinal ring
23
Q
Inguinal vs femoral hernia
A
Inguinal
Superior and medial to pubic tubercle
Still more common in F than femoral
Femoral
Inferior and lateral to pubic tubercle
F>M
Higher risk of stangulation than inguinal because it has a narrower neck
24
Q
How to distinguish between a direct and an indirect inguinal hernia
A
Reduce the hernia and put your hand over the deep inguinal ring
Get patient to cough - if the hernia reappears then it means it is direct (through the abdominal wall)
if it doesnt reappear it means it’s indirect (through the deep inguinal ring which you are blocking with your hands)
deep inguinal ring:
• Midpoint of inguinal ligament
• 1.5cm above midpoint
• Opening in transversalis fascia
25
First line ix for any scrotal mass
USS testis
26
What will intermittent episodes of obstruction make you worry of?
Hernia
27
What is radical orchidectomy performed for and how is it performed?
• Radical orchidectomy done to remove testicular cancer
Performed via an inguinal incision rather than a scrotal incision
o Lymph node supply of scrotal skin is different to that of the inguinal cord + the testicle - you don’t want to spread cancer cells from one compartment (where the testicle drains) to the other (where the scrotal skin drains)
testis - para-aortic
scrotum - inguinal
28
Commonest type of testicular tumour in
20-30 y/o
30-50 y/o
20-30 - teratoma
| 30-50 - seminoma
29
On which testes are varices most common?
Left
o R gonadal vein drains directly into IVC at an oblique angle
o L gonadal vein drains into L renal vein at a 90o angle
30
What does a sudden appearance of L sided varix make you worry of?
Renal tumour compressing the L renal vein and compromising the drainage of the L gonadal vein
31
Commonest causes of epidydimo-orchitis in
Men <35
Men >35
o Men <35 y/o - STIs (consider Chlamydia trachomatis (most common), Neisseria gonorrhoeae)
o Men >35 y/o - UTIs (e.g. Escherichia Coli, Enterobacter, Klebsiella)
o Anal intercourse - increases risk of epididymo-orchitis due to exposure to coliforms
o Others - mumps, Candida
32
Describe idiopathic scrotal oedema
```
Acute onset
Bilateral
Extends into the groin
Not painful
Resolves over 48-72h
Needs no further management
```
(testicular torsion, epididymo-orchitis - would all result in pain)
33
Relative positions of the femoral nerve, artery, vein in the inguinal region
Medial to lateral - VAN
34
Why are smokers more likely to develop hernias and suffer hernia recurrence?
Impaired connective tissue metabolism causing abdominal wall weakness
35
What kind of tumours are bladder cancers?
Most of them are transitional cell carcinomas (90%)
the rest are squamous cell carcinomas and adenocarcinomas
36
Definition of a hydrocele
An excessive collection of serus fluid in the tunica vaginalis
37
Difference between hydrocele and epididymal cyst
Hydrocele - can't separate it from the testis
| Epididymal cyst - can separate it from the testis
38
In which nodes to they drain
testis
scrotum
testis - para-aortic
| scrotum - inguinal
39
Define varicocele
Dilated veins of the pampiniform plexus forming a scrotal mass
more common on the L
associated with infertility
40
Hernia ix
Clinical
| o US – 1st line
41
CKD definition
Irreversible reduction in renal function, chronically abnormal renal function/structure present for MORE THAN 3 MONTHS (with assosciated health implications)
or
GFR <60ml/min for >3m
42
CKD caused by DM vs CKD caused by HTN
DM
US reveals large kidneys
Kimmestiel- Wilson nodules seen on histology - hallmark of diabetic glomerulosclerosis
SGLT2 inhibitors have been shown to slow progression to ESRFe.g. empagliflozin
HTN
US revels small kidneys
ACEi + ARBs
43
Most reliable prognostic factor in CKD
Degree of proteinuria - correlates with the rate of progression of the underlying disease
44
Features of minimal change disease
```
Nephrotic syndrome
Affects children
Related to underlying Hodgkin's disease in adults
Does not progress to ESRF
Podocyte fusion
```
* Podocyte fusion/loss of epithelial foot process on microscopy
* Vacuolation
* Appearance of microvilli
* Normal light microscopy
* Negative immunofluorescence
45
Features of focal segmental glomerulonephritis
Nephrotic syndrome
Affects adults
Can be assosciated with HIV, heroin use or can be idiopathic
Progresses to ESRF
Podocyte fusion, segmental scars on histology
46
Features of membranous glomerulonephritis
Nephrotic syndrome
Most common nephrotic syndrome in adults
Thickening of the glomerular basement membrane
Deposition of immunoglobulin + graular deposits on GBM
Can progress to ESRF
47
What is crescentic glomerulonephritis/rapidly progressive glomerulonephritis?
Nephritic syndrome
- Anti-GBM disease/Goodpasture's syndrome
- Pauci-immune crescentic glomerulonephritis (ANCA)/systemic vasculitis - granulomatosis with polyangiitis, microscopic polyangiiti
- Immune complex-associated (SLE, IgA, post-infectious glomerulonephritis)
Accumulation of macrophages + epithelial cells outside the capllary loops but within Bowman's capsule (fill up Bowman's space)
48
Features of Goodpasture's syndrome
Nephritic syndrome
Autoimmune
Anti-GBM antibodies - affects lung + kidney (attack type IV collagen)
Haemoptysis + haematuria
49
Features of post-strep glomerulonephritis
```
Nephritic syndrome
children
1-2 weeks after URT infection
Strep pyogenes most common bacterium
IgG, IgM, C3 deposits
```
50
Features of IgA nephropathy/Berger's disease
Nephritic syndrome
Macrocopic haematuria immediately following URT or GI infections
Children
Mesangial cell proliferation with matrix expansion
IgA, C3 deposits in matrix on biopsy
51
In AKI there is failure to maintain the homeostasis of... (3)
Fluid - oliguria, volume overload
Electrolyte - hyperkalaemia, hyperphosphataemia, hypocalcaemia
Acid-base - metabolic acidosis
52
what is Hencoh Schonlein purpura
```
Systemic variant IgA nephropathy
Purpuric rash extensor surfaces
Haematuria
Polyarthritis
Abdo pain
Scrotal swelling
```
trad of abdo pain, arthritis, purpuric rash
53
What is pauci immune glomerulonephritis
ANCA associated
Negative immunofluorescence in kidney but positive ANCA
Antibodies bound to neutrophils
Activation within glomerular capillary loops
Many patients will also have vasculitis in other systems e.g. skin rash, lung haemorrhage
54
Causes of acute tubular necrosis
Ischaemia (low CO (HF, MI), hypovalaemia, systemic dilation (sepsis), renal vasoconstriction, hypotension)
Toxins
Drugs
(NSAIDs, ACE-I, ARB, contrast, aminoglycosides (gentamycin), chemo, immunosuppresants (ciclosporin, MTX) myoglobinuria in rhabdomyolysis, myeloma etc.)
55
Electrolyte disturbanes in AKI
Hyperkalaemia
Hyperphosphataemia
Hypocalcaemia
56
What is analgesic nephropathy
Analgesic nephropathy is injury to the kidneys caused by analgesic medications such as aspirin, phenacetin, and paracetamol
Renal papillary necrosis
Chronic interstitial nephritis
57
Consequences of CKD
1. Progressive failure of homeostatic function
- Acidosis
- Hyperkalaemia
2. Progressive failure of hormonal function
- Anaemia
- Renal Bone Disease - Osteomalacia
3. Cardiovascular disease
- Vascular calcification
- Uraemic cardiomyopathy
4. Uraemia and Death
58
UTI definition
The presence of a pure growth of > 10^5 organisms per mL of fresh MSU
Presence of >100,000 of colony-forming units per mm of urine
(1ml = 1000mm)
infection of the kidneys (pyelonephritis), bladder (cystitis), urethra (urethritis) or prostate (prostatitis)
Most common causative organism - E.coli
59
PKD polycystic kidney disease definition
fluid filled cysts grow on the kidney, 10% of ESRF
Autosomal dominant inheritance, onset at 30-60 years
1:1000 (85% of PKD1 Chr16, 15% PKD2 Chr4)
rare AR inheritance on Chr6
60
Where does renal cell cancer arise from?
• RCC originates from the proximal renal tubular epithelium (renal cortex) – lining of the proximal convoluted tubule
also known as von Grawitz tumour, hypernephroma
61
Which genetic condition is assoscated with renal cell carcinoma RCC
```
Von Hippel Lindau
• Common association
• Short arm of Chr 3
• Benign cyst that forms in the CNS, kidneys – younger, bilateral, VHL gene
• Vision loss, retina angiomatosis
```
62
Define renal artery stenosis RAS
* Narrowing of the renal artery lumen
* Considered angiographically significant if >50% reduction in vessel diameter is present
* Important cause of secondary HTN + CKD
63
Causes of RAS renal artery stenosis in
* Older patients
* Younger female patients
* Older patients - Atherosclerosis
| * Younger female patients - Fibromuscular dysplasia
64
Dx for
Muddy brown cast + high creatinine
High urine sodium, low urine osmolality
Low urine:serum urea ratio
Low urine:plasma osmolarity ratio
Acute tubular necrosis
In established acute tubular necrosis, the kidneys can't concentrate the sodium
• Can’t concentrate their urine or conserve sodium
• Urinary sodium >40mmol/L => urine is dilute (osmolarity <350mmol/L)
• Urine:plasma osmolarity ratio <1:1
65
Dx for
Esoinophilic cast, urine dip: protein+blood
Old man, CAP, penicillin Tx, dysuria, back pain
Acute interstitial nephritis
Causes of acute interstital nephritis
- Drugs
- Infection
- Immune disorders e.g. SLE
- Lymphoma
- Tumour lysis syndrome
66
Indications for a 3-way catheter
Recurrent clots
Haematuria
extra lumen for irrigation
https://www.urotoday.com/images/3_way_catheter.jpg
67
Which bacterium can block the cathether by forming a biofilm?
+mx
Proteus mirabilis
1st step - bladder wasout
2nd step - replace catheter
68
How to NSAIDs and ACEi contribute to kidney failure?
NSAIDs --> reduce vasodilation of afferent arteriole (block production of PG)
ACEi --> reduce vasoconstriction of the Efferent arteriole (block conversion of ATI-->ATII)
69
Type of kidney stones that can form in someone who gets recurrent UTIs
Magnesium Ammonium Phosphate (MAP)/Struvite stones
| Associated with chronic UTIs from gram -ve rods that break down urea into ammonia (pseudomonas, proteus)
70
RF for calcium renal stones
Most common
Hyperparathyroidism
Diuretics
Increased gut absorption of Ca
71
Interstitial nephritis can be caused by
```
Infection
NSAIDs
Abx (penicillin, cephalexin)
PPIs
Allopurinol
Phenytoin
Cimetidine
```
72
What is renal osteodystrophy caused by?
Radiological signs?
renal ostedystrophy = alteration of one morphology in pt w CKD - no absorption of Ca, low Vitamin D
- Osteopenia
- Salt + pepper skull
- Subperiosteal erosions
- Brown tumours
- pseudofractures
- Rugger jersey spine
73
What is overflow incontinence?
Overflow incontinence
- involuntary release of urine from an overfull bladder
- occurs in people with blockage of the bladder outlet (e.g. BPH, Prostate cancer)
ix using urodynamic studies
74
Why might dialysis patients suffer from carpal tunnel syndrome?
2y to dialysis related amyloidosis due to depletion of β2 microglobulin
75
Why does renal failure lead to hyperkalaemia
K cant be excreted
Renal tubular damage - inadequate renin secretion and release - hypoaldosteronism - hyperkalaemia
76
What can the use of ACEi in RAS (renal artery stenosis) cause?
```
AKI
Flash pulmonary oedema
Cough
Dyspnoea
Othropnoea
Bilateral fine inspiratory crackles
```
```
Other causes of flash pulmonary oedema
ACEi in RAS
Acute MI
ARDS
Heroin + cocaine use
```
77
Focal segmental glomerulosclerosis
Commonest age group
What is it assosciated with
Histology
older children + young adults
HIV heroin use
* Podocyte fusion
* Segmental scars on histology
78
How to differentiate between a renal cyst, renal abscess, pyelonephritis
Renal cyst
- Usually ASYMPTOMATIC
- Incidental finding on US
Renal abscess
- Persistently high FEVER
- Bacteraemia (+ve blood cultures)
- High WCC
- Severe tenderness on examination
- Non specific symptoms (abominal pain, weight loss, malaise)
- Failure to improve after appropriate therapy
Pyelonephritis
- Systemic symptoms - fever, nausea, vomiting, RIGORS, sweating
- LOCAL symptoms of UTI - dysuria, haematuria, loin pain
79
Give examples of medullary adrenal tumours vs cortex adrenal tumours
medullary - phaechromocytoma
cortex
Conn's syndrome (produces aldosterone)
Cushing's syndrome (produces cortisol)
80
A 67-year-old diabetic female is brought into accident and emergency following a collapse at her home. She was found by her daughter who said she saw the patient going to the toilet and then hearing her collapse. The patient did not lose consciousness and appears well. Her supine blood pressure is 100/70 and standing 115/79. Urine dipstick is positive for glucose, nitrates, leukocytes and haematuria. The most likely diagnosis is:
```
A. Diabetic ketoacidosis
B. UTI
C. Orthostatic hypotension
D. Diabetic nephropathy
E. Hypoglycaemia
```
B. UTI
Severe UTIs - sepsis, hypovolaemia, collapse
Orthostatic hypotenison - drop >20 mmHg in SBP or >10 mmHg in DBP, not just any drop in any BP
Diabetic nephropathy - nephrotic syndorme therefore no haematuria, just proteinuria
Hyoglycaemia - sweating, tachycardia, palpitations, irritability tremor
81
An 18-year-old man presents with general malaise and lethargy for the last 2 weeks, he denies any weight loss and has maintained a good appetite. On examination, there are no abnormalities except for sacral oedema and a polyphonic wheeze. Urine dipstick is positive for protein only and blood pressure is 140/90. The most likely diagnosis is:
```
A. Nephritic syndrome
B. Nephrotic syndrome
C. Goodpasture’s disease
D. Thin-basement membrane nephropathy
E. Minimal change glomerulonephritis
```
E. Minimal change glomerulonephritis
most common cause of nephrotic syndrome in adults + young children
thin basement membrane nephropathy + IgA nephrotpathy
benign conditions
thinning of the GBM
DO NOT IMPACT RENAL FUNCTION - no sacral oedema!!
```
goodpastures triad of
glomerulonephritis
pulmonary damage causing haemorrahge
anti-GBM antibodies
T2 autoimmune rxn
```
Nephrotic syndrome
The nephrotic syndrome (B) is likely in this patient with proteinuria resulting in oedema, however, the cause of these symptoms is minimal change glomerulonephritis, hence this is the best answer.
82
In cases of urethral obstruction, would you get bladder dilation or hydronephrosis first?
Hydronephrosis before bladder dilation
Bladder is a strong muscular organ that requires significant built up of pressure before it becomes dilated
83
A 19-year-old man is recently diagnosed with type 1 diabetes and attends your clinic to ask about possible complications in the future. He mentions an uncle who has end-stage renal disease due to poorly controlled diabetes and specifically enquires about testing for early signs of renal impairment. The most appropriate investigation is:
```
A. Blood pressure
B. Microalbuminuria
C. Serum creatinine
D. Serum electrolytes
E. Urine dipstick for glucose
```
B. Microalbuminuria
urine dipstick is not sensitive enough to detect microaluminuria
Elevation of serum creatinine which is usually excreted by the kidney is a late marker of renal impairment + not appropriate for early risk identification
84
What is a von Grawitz tumour?
RCC
85
A 49-year-old woman attends your clinic suffering from chronic renal failure due to progressive glomerular disease. She appears well and her blood pressure is 141/92 mmHg. Blood tests reveal elevated phosphate, serum creatinine and urea, while calcium levels are low. Her estimated glomerular filtration rate is 35 mL/min/1.73 m2. You also notice the patient’s cholesterol levels are moderately raised. The most appropriate management is:
```
A. Sevelamer
B. Parathyroidectomy
C. Oral vitamin D
D. Cinacalcet
E. Renal dialysis
```
A. Sevelamer = phosphate binder (also lowers Ca and cholesterol)
Hyperphosphataemia can cause vascular calcification
Should be treated asap
Oral vitamin D
Oral vitamin D therapy (C) is useful in early renal disease as it lowers PTH levels, however it is not appropriate as first-line therapy since it increases calcium and phosphate reabsorption and so can inadvertently exacerbate the patient’s symptoms (normally, vitamin D increases Ca absorption + increases PO43- excretion but in CKD, PO43- can't be excreted by the kidney)
High levels of phosphate (which can't be excreted) cause it to find and stick to any available calcium (which is increased if the patient is given vitamin D), which forms bone-like crystals in places that they shouldn’t be
Once phosphate levels have been lowered, vitamin D therapy is then beneficial
86
How to differentiate between Post-infectious glomerulonephritis and IgA nephropathy
Both cause nephritic syndrome (HTN, hameaturia, proteinuria)
Post-infectious glomerulonephritis – tends to occur 4-6 weeks after a streptococcal infection (e.g. streptococcal pharyngitis, cellulitis)
IgA nephropathy – tends to occur 5-7 days after the patient experiences symptoms of pharyngitis
Hypertension – more common in post-strep glomerulonephritis
Heavy proteinuria, systemic symptoms (abdo pain, skin rashes, arthritis) – more common in IgA nephropathy
87
Different types of incontinence
```
Stress incontinence
Urge incontinence
Functional incontinence
Overflow incontinence
Double incontinence
```
Stress incontinence – incontinence when there is increased intra-abdominal pressure
Urge incontinence – detrusor overactivity (neurological problem, intrinsic problem with the detrusor muscle)
Functional incontinence – patients are unable to find a toilet before urinating (immobility, unfamiliar surroundings, not due to a physiological dysfunction)
Overflow incontinence – involuntary release of urine from an overfull bladder (bladder outflow obstruction, detrusor weakness)
Double incontinence – urinary + faecal incontinence (neurological disorders – MS, AD)
