Urology - mx Flashcards
Urethral stricture management options
Cystoscopy to visualise the urethral stricture and then
- Dilation
- Urethral stent
- Cystoscopic urethrotomy
- Surgery to remove the affected portion
Indications for urgent dialysis
- eGFR <10ml/min + benefits outweigh risks
- eGFR <6ml/min + no reversible features
- Life-threatening complications
- Hyperkalaemia (>6.5mM)
- High creatinine (>1000μM)
- Hyperuricaemia (>300mM)
- Symptoms or complications of uraemia (e.g. pericarditis)
- Uraemic encephalopathy
- Fluid overload (severe pulmonary oedema)
- Severe acidosis (pH <7.2) refractory to medical management
- Drug overdose by BLAST drugs – Barbiturates, Lithium, Alcohol, Salicylates, Theophyline
Complications of bladder catheterisation
- UTI (proteus mirabilis) - dysuria, confusion, pyleonephrtis
- Urethral trauma - pain, bleeding
- Urethral scarring + Stricture - slow-flowing micturition, dysuria, urinary retention
- Creation of false passage in the urethra - pain, infection
- Bladder perforation - pain, bleeding, peritonitis
Incontinence management
- Anti-muscarinics (tolterodine, oxybutynin)
PNS - pelvic nerve + Ach receptors –> stimulate contraction of detrusor muscle
SNS - hypogastric nerve + NA receptors –> inhibit contraction of detrusor muscle
To alleviate outflow obstruction
- A adrenergic blockers (doxazosin, prazosin, tamsulosin, afluzosin)
Act on a receptors + block contraction of internal urethral sphincter + SM of prostate capsule
AKI Mx
- Asses volume status + aim for euvolaemia
If pt is dehydrated, stop diuretics
Match daily input to loss + 500ml for insensible loss but more if pyrexic - Withhold drugs that reduce eGFR
- Withhold nephrotoxic drugs (ACEi, ARBs, gentamicin)
- Withhold/reduce drugs that are renally excreted (e.g. metformn if eGFR <30, sulphonylureas, insulin, co-amoxiclav)
- Adequate nutrition
- If using contrast, hydrate patient pre- + post-contrast
- BP control
- Treat the underlying cause
Pre-renal: Correct volume depletion with appropriate fluids, antibiotics (IF sepsis), inotropes (norepinephrine, dobutamine, IF signs of shock)
Post-renal: Catheterise + imaging of renal tract (CTKUB) + urology + reversal
Intrinsic renal: Refer early to nephrology
- Manage complications Hyperkalaemia Pulmonary oedema Uraemia Acidemia
Renal replacement therapy – haemodialysis and haemofiltration if any complications are refractory to medical Mx
Pre-renal azotaemia (high levels of nitrogen compounds in the blood) mx
- IVF +/- blood transfusionIn intrinsic renal failure, if there is pre-existing pre-renal azotaemia, treat with volume expansion
Indications for renal replacement therapy (haemodialysis, haemofiltration)
If renal function does not improve
- Uraemia
- Severe metabolic acidosis
- Hyperkalaemia refractory to medical management (>6.5 mM)
- Volume overload unresponsive to diuretics
Supportive management in patients with AKI
- Intensive control of their a) fluid balance, b) electrolytes
- Oxygenation
- Nutrition
- Glycaemic control
Management of the 6 complications of AKI
Hyperkalaemia** (K+ >6.5mM)
- 10ml 10% IV calcium gluconate/IV calcium
- Calcium resonium
- 10 U actrapid (insulin) + 50ml 50% glucose
or
5U actrapid + 100ml 20% dextrose
- Nebulsied salbutamol
- In an emergency
- Salbutamol nebulisers
- Insulin and dextrose –> They activate the co-transporters on cells which move potassium back into cells and lowers serum potassium for 30-45 minutes
Other answers are used in the treatment of hyperkalaemia but not during emergencies
Hyperphosphatemia (ectopic calcification, secondary hyperparathyroidism, renal osteodystrophy)
- Dietary restriction
- Adminisration of phosphate binders (calcium acetate, calcium carbonate, sevelamer, lanthanum carbonate)
- DialysisPulmonary oedema (hypoxia, hypercapnia, acidosis, SOB)
- Sit up + High-flow O2
- Diuretics - IV furosemide
- Nitrates
- Opiates - diamoprhine 2.5mg IV + cyclizine 50mg
- Non-invasive positive pressure ventilation
- Renal replacement therapy if a) unresponsive to diuretics, b) absence of a reasonable urinary output
Fluid-overload
- Diuretics (careful not to dehydrate patient + give them a pre-renal AKI)
- Renal replacement therapy if unresponsive to diuretics
Acidosis
- Often improves with management of hyperkalaemia
- Sodium bicarbonate 50-100ml of 8.4% IV sodium bicarbonate
Uraemia (pericarditis, encephalopathy, uraemic frost, twitching, hiccups, lethargy, confusion)
- Dialysis
Proteinuria mx
- Control oedema - diuretics, low salt diet
- AT II blockade
- ACEi, ARB
ACEi contraindicated in renal artery stenosis - Treat cause - immunosuppresion/steroids may be needed
Rhabdomyolysis mx
Fluid resuscitation
Immediate urolithiasis management (immediate + general advice)
Immediate
- ABC
- IVF (vomiting - dehydration)
- Multimodal analgesia (paracetamol + PR diclofenac, may need opioids)
General advice
- Increase fluid intake
- avoid red/brown foods - contain oxalic acid that increases stone formation
- Do not cut out dairy products - milk binds to oxalate
Definitive urolithiasis management
kidney stones
Stone <5 mm - allow to pass spontaneously
*Infection - abx, nephrostomy to help drain the kidney
*Obstruction - stent
*No infection/obstruction - conservative management, analgesia + medication to relax the ureters and help them pass the stones
Tamsulosin - a-blocker (superior to nifedipine)
Nifedipine - CCB
* Potassium citrate for uric acid stones
Alkalises urine + dissolves stones + inhibits formation of crystals
Stone >5mm - surgery
*Infection - abx, nephrostomy to help drain the kidney
*Obstruction - stent, precutaneous nephrolithotomy
*No infection/obstruction
ESWL (extracorporeal shock wave lithotripsy) - if small (renal stone <2cm, ureteric stone <1cm)
Flexible URS (ureteronoscopy) removal/Uteroscopic lithotripsy - if too large/contraindcations for ESWL, if patient obese or pregnant
Precutanous nephrolithotomy (PCNL) - third line after ESWL, URS used for large stones (>2cm) staghorn calculi, cysteine stones
Stenting (JJ stent)/precutaneous nephrostomy - if obstruction can’t be resolved surgically, to prevent hydronephrosis
Laparoscopic/open surgery - if ESWL, URS, PCNL fail
EMERGENCY - any signs or an obstructed + infected kidney –> urgent nephrostomy to relieve the obstruction
Abx cover given if any invasive procedure is employed
Causes + Management of
Calcium oxalate + Calcium phosphate stones
- Hypercalciuria - exclude hyperparathyroidism, low-calcium diet
- Hyperuricosuria - allopurinol (inhibits production of uric acid during breakdown of nucleic acids)
- Hypocitraturia - potassium citrate (alkalises urine and inhibits crystal formation)
Causes + Management of Uric acid stones
radiolucent
the only type of kidney stones that dissolves
- Hyperuricaemia
- Gout
- Potassium citrate (alkalizes urine + prevents crystal formation, dissolves stone)
- Allopurinol
Causes + Management of Struvite/ MAP (magnsium ammonium phosphate stones)
2y to infections w urease producing bacterium/ammonia producing organism (break down urea into ammonium)
Most common bacteria: Proteus, pseudomonas, Klebsiella
Treatment of underlying infection
Causes + management of cysteine stones
-Cystinuria (AR w increased cysteine excretion)
- Increase fluid intake
- Potassium citrate
- Cysteine binding drugs given if all else fails (e.g. tiopronin)
5 situations in which patients with urolithiasis will need to be admitted
- Evidence of UTI
Infection proximal to obstruction is a medical emergency and needs surgical drainage - Evidence of renal impairment/failure - raised U, Cr, K
- Refractory pain despite analgesia
- Bilateral obstructing stones/single obstructing stone when 1 kidney present
- Elderly/young/unwell
Surviving sepsis guidelines
- IVF
- O2
- Analgesia
- Abx
- Blood cultures
- VBG
- Assess renal function
- Watch out for intrarenal/perinephric abscess
TURP complications (7)
- TURP syndrome
- Urethral stricture
- UTI
- Incontinence
- Haemorrhage
- Retrograde ejaculation
- Erectile dysfunction
UTI during pregnancy
Which abx to use?
Ok to use
- Penicillins + Cephalosporins (e.g. cephalexin)
- Nitrofurantoins
Not ok to use
- Trimethoprim - folic acid antagonist
- Fluoroquinolones + tetracyclines - teratogenic
- Ampicillin - no longer used because of increased resistance
Vancomycin can also be used but it has to be given IV and is suitable for gram +ve cover, whereas most of the UTIs are caused by gram -ve bacteria (E.coli)
UTI management
a) Females, uncomplicated
b) Females, complicated
c) Males
a) Nitrofurantoin/Trimethroprim
b) Ciprofloxacin (outpatient)
IV gentamicin
(inpatient - Considered for women with fever, increased WCC, emesis, volume depletion in addition to UTI symptoms )
c) TrimethorpimNitrofurantoin (2y option)
b) complicated means not just urological symptoms –> patient is confused, complaints of generalised loin pain, has a temperature
BPH mx
- Emergency – Acute urinary retention – catheterisation
- Conservative – watchful waiting + reduce evening fluid intake
• Medical
o Selective α-blockers (e.g. tamsulosin, alfuzosin) – relax the smooth muscle of the internal urinary sphincter + prostate capsule
o 5α- reductase inhibitors (e.g. finasteride, dutasteride) – inhibit conversion of testosterone to dihydrotestosterone can reduce prostate size by about 20% (work in larger prostates, >30g/ml/cc (cubic centimeters) or PSA >1.4ng/ml)
o PDE-5 inhibitor (phosphodiesterase-5) (e.g. sildenafil/Viagra) – considered for pt with BPH + erectile dysfunction
o Anti-cholinergic agent (e.g. tolterodine) – helps storage/irritative symptoms
• Surgery
o TURP
o Open prostatectomy
o Alternatives
Laser surgery – mutilating (cut the whole lobe out) or ablative (vaporise a bit of the prostate to create a channel)
Rezum/steam – causes prostate tissue to boil + atrophy
Urolift – staples in prostate to staple it to one side + create a channel
Embolization – cuts off the blood supply
Catheter options
Management of overactive bladder/incontinence
• Management of overactive bladder (management of storage symptoms caused by overactive detrusor muscle)
o Conservative management – reassure, dietary advice (caffeine, citrus fruit can really irritate the bladder), bladder retraining exercises
o Medical management – anticholinergics (e.g. tolterodine, oxybutinin, detrusitol, solifenacin), β-agonists (betmiga)
o Surgical management – intravesical Botox injection
Testicular cancer mx
• Radical R/L orchidectomy
• Radical orchidectomy performed via an inguinal incision rather than a scrotal incision
o Removing malignant testes through scrotal incision - risk of seeding malignant cells into scrotum during the procedure
o Lymph node supply of scrotal skin (inguinal nodes) is different to that of the inguinal cord + the testicle (para-aortic nodes) you don’t want to spread cancer cells from one compartment (where the testicle drains) to the other (where the scrotal skin drains)
• Collect sperm prior to procedure – safeguard against reduction in fertility after surgery/radiotherapy
- Seminomas highly radiosensitive
- Teratomas are not radiosensitive
• Post-op – surveillance +/- chemo +/- radio +/- RPLND (retroperitoneal lymph node dissection)
• Seminoma
o Chemotherapy (carboplatin) post orchiectomy
o External beam radiation post-orchidectomy
• Teratoma
o RPLND post-orchidectomy
o Chemotherapy post-orchidectomy
• Advanced cancer/metastasis
o Combination chemotherapy post-orchidectomy
following orchidectomy seminomas with metastases are treated using chemo
Testicular torsion mx
• Do not delay surgery (90% of rescuing tests at 6h, 5% at 24h, testicular necrosis >24h)
o Emergency scrotal exploration + operative repair within 6h of the onset of symptoms
o If there is delay in reaching theatre - attempt manual de-rotation of the testis (outwards rotation)
o Bilateral orchidopexy - suturing the testicle to the scrotal tissue to prevent recurrence
o If testicle is necrotic - orchidectomy
• Supportive care
o Analgesia (morphine sulfate)
o Anti-emetics (ondansetron)
Urinary incontinence mx
o Conservative management – reassure, dietary advice (caffeine, citrus fruit can really irritate the bladder), bladder retraining exercises
o Medical management
Anticholinergics (e.g. tolterodine, oxybutinin, detrusitol, solifenacin)
β-agonists (betmiga)
o Surgical management – intravesical Botox injection
Epidydimo-orchitis mx
• Bacterial infection
o Gonorrhoea/Chlamydia – ceftriaxone + doxycycline
o Gonorrhoea/Chlamydia/enteric organisms – ceftriaxone + ofloxacin/levofloxacin
o Enteric organisms – ofloxacin/levofloxacin
o Mycoplasma genitalium – moxifloxacin
o NSAIDs/paracetamol
• Idiopathic/viral
o NSAIDs/Paracetamol
• TB
o Treat with systemic abx to local guidelines (highly variable TB strains + abx resistance patterns)
• Severe epididymo-orchitis w features of bacteraemia
– IVF
– Electrolyte imbalance correction
– IV broad-spectrum abx (cefuroxime)
CKD management
1) Limit progression/complications
BP: target <130/80 ( <125/75 is diabetic)
Tight glucose control in DM
Decrease CVS risk ( stop smoking, lose weight etc)
Diet: moderate protein, restrict K+, avoid high phosphate foods
Renal osteodystrophy:
- Calcichew - Ca supplement
- Calcium acetate - phosphate binders
- Cinacalcet (calcimimetic) – reduce PTH levels
Symptom control
- Anaemia: Human EPO might be required
- Acidosis: Consider sodium bicarbonate supplements for patients with low serum bicarbonate.
- Oedema: loop diuretics, restriction of fluids
CKD mx
Education + lifestyle
BP control
Aim for <140/80
DM w ACR >70 - <130/80
ACEi/ARB if ACR>70, ACR >30 + HTN, ACR >3 + DM
Statins
Offer to all w CKD
Atorvastatin 20mg
Immunisations
Name 2 potassium sparring diuretics
Spironolactone
Amiloride
First line mx for nephrotic syndrome
Fluid restriction
Diuretics
Consider Prophylactic anticoagulation + discourage bed rest (hypercoaguable state)
