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Y3 Charis > Urology - ix > Flashcards

Urology - ix Flashcards

1
Q

Ix for AKI

A 
Bedside
- Urine dip
   Blood - UTI, stones, malignancy
   Protein - intrinsic renal disease
   Nitrates + Leukocytes - UTI, pyelonephritis 2o to stones
   Glucose
   Specific gravity
  • Bladder scan
    Obstructive picture
  • ECG
    Can show ppt cause (e.g. MI)
    Can show complications - pericarditis, hyperkalaemia (flattened P waves, wide QRS, tall T waves)

Bloods
- U+E, Cr, K
Will confirm renal impairment
High serum urea + creatinine
Ca goes down + Phosphate goes up very quickly in renal failure
Baseline for monitoring the patient’s progress
- FBC, LFT, CRP, ABG, Blood cultures if infection is suspected

Imaging
- USS KUB
Used if pt is truly anuric, signs of sepsis present
Urinary tract obstruction, kidney size, kidney structure Inflammation of the kidneys
Hydronephrosis

  • CT KUB
    If you suspect renal stones
  • CXR if fluid overloaded
Other tests
- Renal biopsy - glomerulonephritis 
- MSU
  MC+S
   Red cell casts - glomerulonephritis
   Bence Jones protein - myeloma screen
- Urine biochemistry - may help distinguish prerenal failure from established acute tubular necrosis
- Features of systemic disease
    ANCA (systemic autoimmune vasculitis), Anti-GBM, SLE immunology (ANA, dsDNA, complements) 
- Creatine kinase
    ?Rhabbomyolisis
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2
Q

Difference between prerenal failure + acute tubular necrosis + SIADH

A

Prerenal failure

  • Kidneys retain salt + water
  • Urinary sodium <20 mmol/L
  • Urine is concentrated (osmolarity >500mmol/L)
  • Urine:plasma osmolarity ratio >1.5:1

Established acute tubular necrosis

  • Can’t concentrate urine or conserve sodium
  • Urinary sodium >40 mmol/L
  • Urine is dilute (osmolarity <350mmol/L)
  • Urine:plasma osmolarity ratio <1:1

SIADH

  • Excess water reabsorbed from kidneys
  • Low serum Na, low plasma osmolarity
  • High urine Na (since most of the water has been reabsorbed), high urine osmolarity
  • Urine is concentrated
  • Plasma is dilute
  • Urine osmolarity > plasma osmolarity
  • Urine : plasma osmolarity >1:1
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3
Q

Ix for CKD

A
  • Urine dipstick + microscopy (protein, glucose, ACR)
    To exclude infection
    Albuminuria - glomerular/tubointestritial disease, UTI
    Macroscopic haematuria - renal cell carcinoma, renal calculi, UTI
    Red blood cell casts - glomerulonephritis
    White cell casts - Interstitial nephritis, UTI
    (if there is proteinuria, send ACR - if ACR 30-300mg/g for >3 months - CKD
  • Serum + protein electrophoresis, urine BJP Protein electrophoresis
  • monoclonal band
    Bence Jones protein (monoclonal protein) possibly representing multiple myeloma
  • GFR
    Gold standard measurement
    Assessment of renal function
  • USS KUB
    To exclude obstruction
    To assess kidney size
  • Biochemistry (hypocalcaemia, hyperkalaemia, hyperphosphataemia, high ALP in renal osteodystrophy, high PTH if seconday hyperparathyroidism)
  • Haematology (normocytic anaemia)
  • Serology
  • Urine
  • ECG + echo
  • CXR - pericardial effucion or pulmonary oeddema
  • Imaging of the renal tract
  • Renal biopsy - considered once prerenal + postrenal disease have been excluded (esp if structure + size are normal on US –> suggests a more acute cause)
  • Glucose (diabetic glomerulosclerosis)
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4
Q

Biochemistry in CKD (rheumatology)

A
  • c-ANCA - granulomatosis with polyangiitis (Wegener’s)
  • p-ANCA - microscopic polyangiitis
  • Anti-GBM - goodpastures
  • ds DNA, ANA - SLE
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5
Q

Imaging of the renal tract CKD

A
  • AXR - radio-opaque stones, nephrocalcinsis
  • US
    Small kidneys in advanced CKD
    Large kidneys in diabetic nephropathy
    Structural abnormalities e.g. polycystic kidneys, hydronephrosis, to exclude obstruction
  • CT KUB
    To define renal masses, cysts, most sensitive test for identifying renal stones
  • MRI - contraindications to CT
  • Renal angiography - renal artery stenosis
  • Dupplex scan kidneys
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6
Q

Indications for renal biopsy

A
  • Acute renal impairement
  • Haematuria
  • Proteinuria (suggests glomerular disease)
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7
Q

Urine results in glomerular disease, tubular disease, pre-renal renal failure

A

Glomerular disease - red cells, red cell casts, proteinuria (often heavy)
Oliguria not a common presentation of AKI
Proteinuria is always glomerular disease

Prerenal failure
• Kidney retains salt + water
• Urinary sodium <20mmol/L => urine is concentrated (osmolarity >500mmol/L)
• Urine:plasma osmolarity ratio >1.5:1

Established acute tubular necrosis
• Can’t concentrate their urine or conserve sodium
• Urinary sodium >40mmol/L => urine is dilute (osmolarity <350mmol/L)
• Urine:plasma osmolarity ratio <1:1

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8
Q

Painless haematuria investigations

A

> 40

  • suspect tumours
  • Cystoscopy
  • Urine cytology
  • CT/US/IVU

Young pt - more likely to have a renal cause (thin glomerular membrane, igA nephropathy (glomerular dissaes, igA deposits in mesangium), Alport’s syndrome (deafness, heamaturia, inherited, sex linked)

  • Renal function tests
  • Blood tests for underlying systemic immune disease
  • Biopsy to confirm dx
    CT urogram or KUB – gold standard

Ix
Kidneys + ureters show clearly on CT
Flexible cystoscopy
Bladder doesn’t look clearly on CT, go for cystoscopy – might miss a bladder tumour w CT

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9
Q

Features of CKD

A

Pt only gets symptoms when eGFR falls to very low levels (i.e. <30 ml/min/CKD 4/5)

  • Fatigue
  • Malaise
  • Thirst
  • Anorexia
  • Nausea
  • Itching
  • Uraemic skin (lemon yellow, bruises)
  • HTN
  • Small scarred kidneys
  • Anaemia
  • Metabolic acidosis (not hypoxic)
  • Hypocalcaemia
  • Hyperphosphataemia 2o hyperparathyroidism
  • Low to normal [Ca], high PTH, low plasma [Ca] due to e.g. renal failure, vitamin D deficiency stimulates release of PTH to try to normalise serum calcium
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10
Q

Rhabdomyolysis biochemistry

A
  • Raised CK (x5 normal)
  • Raised U+Cr
  • Raised K, Mg, PO43-
  • Low Ca
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11
Q

Polycystic kidney disease PKD

A
  • US (first line)
  • CT AP (second line)
Bloods
•	FBC
o	Hb – polycystic kidneys can produce EPO which increases Hb
•	U+E, Cr
o	Creatinine often normal
Imaging
•	Renal US
o	Cysts in kidneys 
o	Renal enlargement
•	CT/MRI AP - 2nd line

• Urinalysis
o To detect proteinuria -higher likelihood of progression to CKD, higher incidence of LVH
o Microscopic + macroscopic haematuria common
o Check for UTI

• CT brain
o If sudden-onset severe or unusual headache
(pt w PKD at risk of intracranial aneurysm or SAH)

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12
Q

Ix for

a) SLE
b) Multiple Myeloma
c) Pre-renal renal failure
d) Rhabdomyolysis
e) Bladder tumour

A

a) anti-nuclear ab
b) Protein electrophoresis - monoclonal band
c) Volume status + BP (hypovolaemia, dehydration)
d) Serum CK
e) Cystoscopy

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13
Q

Urolithiasis ix

kidney stones

A
  • Bedside - Pregnancy test
    to exclude ectopic pregnancy + bc pt will undergo a CT scan
  • Urine dipstick
    Microscopic haematuria
  • CT KUB - 90% of renal stones are radio-opaque
    First line for kidney/ureteric stones, gold standard
    Pyelonehritis, hydronephrosis, +/or hydroureter due to obstruction - signs of inflammation around the kidneys - perinephric fat stranding
    Will also detect AAA
  • Serum calcium, phosphate, urate, uric acid level
    High uric acid/calcium - kidney stones
    Should be requested on anyone with a proven stone to look at its components and decide on treatment

Bloods
- U+Es, Cr
Check renal function - AKI, hydronephrosis, hyperkalaemia
Cr/U might be up because of dehydration
If both U+Cr are up - renal injury (e.g. acute tubular necrosis)

Usually no fever with kidney stones

-MRU if pregnant

  • US KUB if pregnant
    Doesn’t show stones in ureter
    Will show hydronephrosis, stones in the kidney
    Will not tell you if an AAA is bleedingAny pt w flank/back/abdo pain + AAA on US –> contrast CT to look for a leak of their AAA
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14
Q

Hyperkalaemia findings on ECG

A
  • Prolonged PR
  • Widened QRS
  • Tall tented T waves
  • Absent P waves

Severe hyperkalaemia - sinusoidal waves

> 5.5 mM Tall tented T waves
6.5 mM Flattening of p waves
7.5 mM Prolonged PR + QRS intervals, bradycardia

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15
Q

Renal US scan offered to all people with CKD who… (6)

A
  • Have an accelerated progression of CKD
  • Have visible/persistent invisible haematuria
  • Have symptoms of urinary tract obstruction
  • Have a FHx of PKD and are >20 y/o
  • Have a GFR <30 ml/min/1.73m2
  • Are considered by a nephrologist to require renal biopsy
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16
Q

Ix for glomerulonephritis/nephrotic syndrome

A
  • Urinalysis
  • MSU
    To exclude UTI
  • ACR
    Always ordered as a follow up to urinalysis showing proteinuria
  • Bloods
    Anaemia - renal failure
    Hyperlipidaemia in nephrotic syndrome
    LFTs - if Hep B/C suspected
    ESR/CRP - if systemic inflammation e.g. vasculitis suspected
    Fasting glucose
    Autoimmune screen if underlying autoimmune disease is suspected
    Serum albumin low in nephrotic syndrome (<30g/L)
    Increased K+, Increased PO43-, Low HCO3- in renal failure
  • eGFR
  • Imaging
    USS KUB - size of kidneys, to exclude obstructive uropathy
  • Ig, serum, urine electrophoresis
    Increased gamma globulin –> SLE, amyloidosis, lymphoma
    Increased monoclonal paraprotein –> myeloma, AL (light chain) amyloidosis
  • Renal biopsy
    If intrinsic kidney disease is suspected
    Urgently performed if GN is suspected
     Nephrotic syndrome is most commonly caused by glomerulonephritides 
 Adults should all get a renal biopsy  In Children the most common cause of nephrotic syndrome is minimal change disease/glomerulonephritis - normally reverses with steroids [biopsy can be avoided unless there are other concerning features or little response to steroids]
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17
Q

How ix the following

a) Pt w known IHD taking ACEi + develops renal failure
b) 24yo long distance runner w R sided groin pain + vomiting
c) 65yo M poor stream, terminal dribbling, hesitancy
d) 75yo F confusion, dysuria, fever
e) 35 yo urinary incontinence following coughing or sneezing

A

a) RAS - MR angiography
b) Kidney stones - CT KUB
c) Urinary tract obstruction - US KUB
d) UTI - urine dipstick, MC+S
e) Stress incontinence - urodynamic studies

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18
Q

Urine results in tubular disease

A

Tubular disease - minimal blood, small urine, granular/white cell casts

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19
Q

Urine results in pre-renal renal failure

A

Pre-renal renal failure - nothing abnormal in urine

20
Q

BPH ix

A

• Urine dip = exclude infection

• DRE
Enlaeged, smooth, firm, elastic, free from prostate, obliterated median sulcus/palpable midline groove

• Bloods
o U+Es – impaired renal function
o PSA - suggests underlying prostate cancer or prostatitis (N PSA: <4 ng/ml)
o LFTs
 Increased ALP – of prostate cancer has metastasised to the bone
 Increased ALP – in an elderly person w undiagnosed Paget’s disease of bone

• Flow rate + postvoid residual bladder scan in clinic
o If flow is <12 ml/s - obstructed flow
o Do not routinely offer this to men with LUTS at initial assessment

Ix to consider
• Imaging
o US urinary tract - ?hydronephrosis
o Bladder scan – measure pre- and post-voiding volumes
o TRUS (transrectal US) – assessment of bladder size + volume

21
Q

Prostate cancer ix

A
  • DRE
    Irregular, stony hard, nodule within one lobe, enlarged, asymmetry of the gland, induration of part or all the prostate, lack of mobility

• Multiparametric MRI – recommended by NICE as a FIRST LINE IX for pt suspected clinically of having localised prostatic cancer
o Positive MRI scan – move onto biopsy
o Negative MRI scan – reassure + continue monitoring PSA levels, ask them to come back if PSA starts rising significantly

• PSA Test

• Prostate biopsy
o TRUS biopsy (transrectal biopsy of the prostate guided by US) - risk of sepsis, bleeding
o Now carried out
 Transperineally biopsy
 Classic picture: hypoechoic area in the peripheral zone of the prostate

• LFTs/bone profile - check for metastatic disease
Ix to consider
• PCA3 urine test
o Superior to PSA total
o Indication: to determine whether a man needs a repeat biopsy after an initially negative biopsy outcome

Staging - TNM - MRI/Bone scan

22
Q

PSA Values

A

PSA <4 ng/ml Very low risk of prostate cancer
PSA 4-10 ng/ml Moderate risk of prostate cancer
PSA >10 ng/ml High risk of prostate cancer
PSA >40 ng/ml High risk of metastatic prostate cancer
PSA >100 ng/ml Almost certainly metastatic prostate cancer

Normal PSA <4ng/ml

23
Q

TURP complications

A

 Retrograde ejaculation – you ejaculate up into the bladder bc internal urinary sphincter is relaxd
 Erectile dysfunction
 Haemorrhage
 Urinary infection
 Urethral stricture
 Incontinence
 TURP syndrome – seizures or cardiovascular collapse caused by hypervolaemia + hyponatramia due to absorption of glycine irrigation fluid

24
Q

Testicular cancer ix

A

• USS of both tests – FIRST LINE TEST, urgent on the same day
o If US does not confirm a mass + suspicion is high (e.g. abnormal tumour markers) proceed to CT AP

• Tumour markers (if USS highly suggestive of a tumour)
o Aid Dx
o Monitor response to treatment
o Monitor for relapse
o α-fetoprotein (AFP) – 50-70% of teratomas, not seminomas
o β-human chorionic gonadotrophin (β-HCG) – 40-60% of teratomas, 30% of seminomas
o gamma glutamyl transpeptidase (GGT) – 33% of seminomas
o LDH – less specific, elevated in many cancers as it’s released during tissue breakdown, most commonly raised in seminomas but in testicular cancer used mainly to asses tumour burden

• Staging scans
o Plain CXR on the same day
o CT CAP (chest abdo pelvis) – used to assess extratesticular metastasis, might show enlarged retroperitoneal lymph nodes

A biopsy is generally not advised in the evaluation of a testicular mass due to risk of seeding; diagnosis is established by removing and examining the involved testicle.
o Cystic spaces – teratoma
o No cystic spaces – seminoma

25
Q

Testicular torsion ix

A

• Power/colour Doppler/Duplex US of the tests

• Arterial inflow
o Decreased in testicular torsion
o Increased in epididymo-orchitis

• Grey-scale US
o Whirlpool sign (the swirling appearance of the spermatic cord from torsion as the US probe scans  perpendicular to the spermatic cord)
o Presence of fluid

(CRP is not raised in testicular torsion
(scintigraphy decreased uptake of radioactive technetium – 99m to the affected testicle)

If a patient present with testicular torsion acutely, first line ix is exploratory surgery as you only have 6h to save the testis

26
Q

First line ix for any scrotal mass

A

USS testis

27
Q

Bladder cancer ix

A

• Cystoscopy + biopsy
o Low grade tumours – papillary + readily visible
o High grade tumours – flat + more difficult to see

  • Urinary cytology
  • Urinalysis – haematuria
  • MRI/CT – for staging
28
Q

Hydrocele ix

A

Ultrasound - exclude tumour
Testicular tumour markers – AFP, βHCG, GGT, LDH
Urine dipstick/MSU – check for infection

29
Q

Epididymo-orchitis ix

A

• Exclude STI
o Gram-stained urethral smear
o Urethral swab for Gonorrhoeae, Chlamydia trachomatis

• Exclude UTI
o Urine dipstick
o MSU microscopy + culture

  • Exclude testicular torsion – Duplex USS
  • Bloods – if septic
  • Ix of the urinary tract to detect anatomical abnormalities that can predispose someone to UTI
  • TB – 3x early morning urine samples (acid-alcohol fast bacilli)
  • Mumps – mumps IgM/IgG serology
30
Q

Hernia ix

A

Clinical

o US – 1st line

31
Q

Post-strep Glomerulonephritis ab

A

Anti-DNase
Anti-hyaluronidase
Anti-Streptolysin O

32
Q

Diabetic nephrotpathy on histology

A

Mesangial expansion
BM thickening
Glomerulosclerosis

33
Q

UTI ix

A

• Dipstick
o Nitrites, Leukocytes

• Urine MC+S
o Gram negative bacilli!! - E. coli!

34
Q

US diagnostic criteria for PKD polycystic kidney disease

A

For individuals with positive FHx
• >2 unilateral/bilateral renal cysts at age >30 years
• >2 bilateral cysts bn 30-59
• >4 bilateral cysts at age >60
• Dx is supported by hepatic/pancreatic cysts

For individuals w/out FHx
• >10 cysts in each kidney
• No manifestations suggesting an alternative renal disease

35
Q

Renal cell carcinoma RCC ix

A
  • There is often no abnormality on examination
  • Exclude UTI – urinalysis, cytology, culture, sensitivity
  • Cystoscopy to exclude bladder cancer as a cause of haematuria
  • Renal function tests will be normal if one kidney is functioning well
  • Increased blood pressure - renin release
•	FBC
o	Iron deficiency anaemia (haematuria)
o	Polycythaemia (some RCC produce EPO + Increased Hct)
o	Increased ESR
o	Increased Ca

• US abdo/pelvis
o Appropriately sensitive initial imaging for determining if cystic renal lesions are benign, especially in hereditary syndromes prone to cystic disease

• CT abdo/pelvis
o Definitive test for dx + staging of RCC

• Renal biopsy

• Metastases (commonly metastasises to lungs + bones)
o CXR – Canon ball secondaries in lung
o LFTs - raised transaminases (AST, ALT) + poor liver function (PT>14s, APPT >34s)
o Skeletal survey/bone scan
o Brain CT
o raised ALP

36
Q

renal artery stenosis RAS ix

A

Bloods
• U+Es, eGFR
o Hypokalaemia may suggest RAS due to activation of the renin-angiotensin system

  • Blood glucose
  • Lipid profile – renovascular disease is likely to be part of a more extensive atherosclerotic disease

• Aldosterone : Renin
o <20 - excludes primary aldosteronism as a case of HTN + hypokalaemia
o High aldosterone + high renin

Urine
• 24h urinary protein excretion
In the absence of diabetic nephropathy or HTN glomerulosclerosis, RAS is not associated with proteinuria
• Urinalysis to exclude RBC/red blood cell casts (glomerulonephritis)

Imaging
• Conventional angiography/Renal arteriogram (digital subtraction renal angiography)
o Gold standard
o Most sensitive + specific test in the evaluation of RAS
o Invasive
o >50% reduction in vessel diameter
o Endovascular therapy can be carried out at the same time

• MRI angiography - Amir Sam mentions this in his lecture (DPD6) as the gold standard
o Can be used to assess blood flow rate, renal perfusion rate, GFR
o Visualises the renal arteries and peri-renal aorta
o Has only been validated for disease in the proximal renal arteries
o Safer than conventional angiography as it does not use nephrotoxic contrast medium

• Renal US
o Performed in those with renal impairment
o Not diagnostic for renovascular disease
o Dx suggested if there is a significant difference (>1.5cm) in kidney size - asymmetrical kidneys

• Dupplex renal US
o Measures flow velocity in renal artery stenosis as a means of assessing the severity of the stenosis

37
Q

Varicocele ix

A

• Examination with the patient standing
o Scrotum w varicocele hangs lower than on N side
o Valsalva manoeuvre whilst standing increases dilation
o There may be a cough impulse
o Palpation of the spermatic cord above the testicles – “back of worms” appearance

• US – venous dilation >2cm

• Colour Doppler studies
o Used as adjunct to physical examination - not indicated unless physical examination is inconclusive
o Colour demonstrates direction of blood flow (incl. reverse flow in the varicocele)
o If the varicocele comes on quickly it can be caused by a renal tumour which raided into the testicular vein + caused the veins around the testicle to obstruct + dilate

38
Q

Dx of urethral strictures

A

Urethrography
Dye is inserted through the distal end of the meatus
Dx of strictures, determines their length and number

39
Q

Gold standard ix for all urinary incontinence

A

Urodynamic studies

40
Q

A 61 y/o man complains of hesitancy, poor stream, terminal dribbling
Distended badder suprapubically
Which ix

radionuclide studies
urodynamic study
abdominal US
Bladder scan
cystoscopy
A

Urodynamic study

Overflow incontinence

  • involuntary release of urine from an overfull bladder
  • occurs in people with blockage of the bladder outlet (e.g. BPH, Prostate cancer)

Gold standard ix for all urinary incontinence –> Urodynamic studies

41
Q

Goodpasture’s syndrome

antibodies
renal biopsy
immunofluorescence

A

Ab trigger a T2 hypersensitivity reaction – renal failure, pulmonary haemorrhage, haemoptysis
Anti-GBM antibodies

Renal biopsy = focal/diffuse crescentic glomerulonephritis

Immunofluorescence = IgG ab, C3 complement deposition on GBM

42
Q

Antegrade vs retrograde pyelography

A

Antegrade - to ix potential area of obstruction within the kidney

Retrograde - to ix obstruction via a catheter

43
Q

Analgesic nephrotpathy vs acute tubulointerstitial nephritis

A 
Analgesic nephrotpathy 
chronic NSAID use
haematuria
Anaemia 
UTI 
Acute tubulointerstitial nephritis 
drug hypersensitivity reaction
fever
rash
arthralgia
oesinophilia
44
Q

Diabetic nephropathy

A

Progressive damage to the filtering capacity of the kidneys
US reveals large kidneys
Kimmestiel- Wilson nodules seen on histology - hallmark of diabetic glomerulosclerosis
Initial increase in GFR

glomerulosclerosis allows passage of protein into urine but not blood - nephrothic syndrome

SGLT2 inhibitors have been shown to slow progression to ESRF e.g. empagliflozin

45
Q

Pyelonephritis on CT

A

Gas accumulation due to parenchymal infection

gram -ve infection commonly

Y3 Charis (35 decks)

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