genitourinary

Question 1

wtf is acute kidney injury? + complications

Answer 1

acute drop in kidney function diagnosed measuring increased serum creatinine (waste product produced by muscles and filtered by kidneys into urine)

NICE Criteria:
Rise in creatinine ≥ 25 micromol/L in 48 hours
Rise in creatinine of ≥ 50% in 7 days
Urine output of < 0.5ml/kg/hour for > 6 hours

complications -
hyperkalaemia (kidney not filtering out into urine)
fluid overload, heart failure, pulmonary oedema
metabolic acidosis
uraemia (high urea) - can lead to encephalopathy or pericarditis

Question 2

risks and causes of an AKI?

Answer 2

RF:
chronic kidney disease, heart failure, diabetes, liver disease, older age (65+), cognitive impairment, use of contrast medium eg. during CT scans, nephrotoxic medications eg. NSAIDS and ACE inhibitors

Causes:
PRE-RENAL =
most common cause, due to inadequate blood supply to kidneys which reduces filtration of blood (which may be due to dehydration, hypotension/shock, heart failure)

RENAL=
intrinsic disease in kidney has lead to reduced filtration of blood (which may be due to glomerulonephritis, interstitial nephritis, acute tubular necrosis)

POST-RENAL =
caused by obstruction to the outflow of urine causing a back-pressure into kidney hence reduced kidney function = obstructive uropathy!
(which may be caused by kidney stones, masses such as cancer in abdomen/pelvis, ureter or uretral strictures (narrowing), enlarged prostate/prostate cancer)

Question 3

manage AKI?

Answer 3

prevention =
avoid nephrotoxic meds, adequate fluid input for unwell patients (IV)

treatment =

• fluid rehydration with IV (pre-renal)
• stop nephrotoxic meds such as NSAIDS and antihypertensives like ACE inhib (bc they reduce filtration pressure)
• relieve obstruction eg. insert catheter if enlarged prostate

may need dialysis in severe cases

Question 4

wtf are kidney stones? + types

Answer 4

also known as renal calculi/colic, urolithiasis and nephrolithiasis
hard stones that form in renal pelvis
may be asymptomatic until they irritate/cause obstruction in ureters, commonly get stuck at the vesico-ureteric junction

types:

calcium stones =

• most common (80%)
• raised serum calcium/hypercalcaemia and low urine output
• 2 types: calcium oxalate, calcium phosphate

uric acid = not visible on x-ray
struvite = produced by bacteria hence associated with infection
cystine = cystinuria (autosomal recessive disease)

staghorn calculus =

• stone forms in shape of renal pelvis (horns extend into renal calyces)
• may be seen on plain x-ray films
• normally made of struvite
• in recurrent UTIs, bacteria can hydrolyse urea to ammonia = solid struvite

Question 5

presentation of kidney stones?

Answer 5

may be asymptomatic
renal colic - unilateral loin to groin pain, colicky as stone moves and settles (fluctuating in severity)
restlessness

may also be:
Haematuria
Nausea or vomiting
Reduced urine output
Symptoms of sepsis, if infection is present

Question 6

investigate kidney stones?

Answer 6

• urine dipstick (usually shows haematuria), can also be used to exclude infection
• blood test can show signs of infection and show kidney function eg. hypercalcaemia
• abdominal x-ray can show calcium-based stones (but not uric acid as is radiolucent)
• non-contrast computer tomography (NCCT) of kidneys, ureters, bladder (CT KUB) is initial investigation within 24 hours of presentation
• ultrasound of KUB is less preferred alternative to CT as neg result does not exclude stones, less effective at identifying but used if pregnant or child
• analyse stones to help determine risk and avoid recurrence

Question 7

hypercalcaemia is a cause of kidney stones. presentation of hypercalcaemia? (mnemonic) + 3 main causes

Answer 7

renal stones, painful bones, abdominal groans and psychiatric moans

calcium supplementation, hyperparathyroidism and cancer (eg. myeloma, breast or lung cancer)

Question 8

management of kidney stones?

Answer 8

• NSAIDs most effective analgesia eg. intramuscular diclofenac (IV paracetamol if NSAID not suitable)
• antiemetics for nausea/vomiting eg. metoclopramide
• antibiotics if infection
  watchful waiting in stones less than 5mm
• tamsulosin (alpha-blocker) to help aid spontaneous passage of stones
• surgery

Question 9

surgical interventions for kidney stones?

Answer 9

Extracorporeal shock wave lithotripsy (ESWL):
external machine, shock waves directed at stone to break into smaller parts

Ureteroscopy and laser lithotripsy:
camera via urethra, bladder, ureter
stone identified and broken by lasers

Percutaneous nephrolithotomy (PCNL):
under general anaesthetic
nephroscope (camera) inserted via small incision on patients back
nephrostomy tube may be left in place to drain kidney

open surgery:
rare, invasive

Question 10

how are recurrent kidney stones treated?

Answer 10

• increase oral fluid intake (2.5 - 3l per day)
• add lemon juice to water as citric acid binds to urinary calcium
• avoid carbonated drinks due to phosphoric acid which promotes calc oxalate formation
• reduce dietary salt intake ( <6g per day)
• normal calc intake

reduce the intake of oxalate-rich foods (for calc)
educe the intake of purine-rich foods (for uric)
limit dietary protein

meds - potassium citrate, thiazide diuretics eg. indapamide

Question 11

wtf is prostate cancer? + RF

Answer 11

• most common cancer in men
• majority are adenocarcinomas and grow in peripheral zone of prostate
• many are very slow growing
  advanced cancer spreads to lymph nodes and bones
• almost always androgen-dependent meaning they rely on androgen hormones eg. testosterone

RF:
increasing age
family history
black afro/Caribbean origin
tall
anabolic steroids

Question 12

presentation of prostate cancer?

Answer 12

may be asymptomatic
lower urinary tract symptoms - hesitancy, frequency, weak flow, terminal dribbling, nocturia
haematuria
erectile dysfunction
symptoms of advanced decease/red flags - weight loss, bone pain, cauda equina syndrome (nerves in lower back become compressed causing numbness in legs)

Question 13

what is PSA and PSA testing?

Answer 13

epithelial cells of the prostate produce prostate-specific antigen (glycoprotein secreted in semen, small amount enters blood)
enzymatic activity helps thin the thick semen into a liquid consistency after ejaculation
not produced anywhere else in body
raised level can indicate prostate cancer

testing is unreliable but can lead to early detection
common causes of raises: cancer, benign prostatic hyperplasia, prostatitis, UTI, exercise, recent stimulation

Question 14

investigate for prostate cancer?

Answer 14

prostate exam DRE:
benign prostate = smooth, symmetrical, soft, central sulcus
prostatic hyperplasia = generalised enlargement
infected/inflamed prostate/prostatitis = enlarged, tender, warm
cancerous prostate = firm, hard, asymmetrical, craggy, irregular, loss of central sulcus, hard nodule
cancer suspicion leads to 2 week wait urgent referral

multiparametric MRI:
first line
likert scale -
1 very low
2 low
3 equivocal
4 probable
5 definite

prostate biopsy:
based on exam, psa level, likert 3+
false-negative if cancerous area is missed
multiple needles used to target diff areas
-Transrectal ultrasound-guided biopsy (TRUS) = probe inserted into rectum
- Transperineal biopsy = needles into perineum under LA

isotope bone scan:
radioactive isotope is given by intravenous , bones absorb, gamma camera is used to take pictures of skeleton, metastatic bone lesions take up more of the isotope

gleason grading:
histology of biopsies
1-10, higher score = cells have mutated further from normal prostate tissue = worse prognosis
6 = low
7 = intermediate
8+ = high

TNM staging:
T (tumour), N (lymph nodes) and M (metastasis)

Question 15

manage prostate cancer?

Answer 15

Surveillance or watchful waiting in early prostate cancer
External beam radiotherapy directed at the prostate (can cause proctitis - inflam in rectum, Prednisolone suppositories can help reduce this)
Brachytherapy (radiation source inserted near tumour, can cause inflam of nearby organs)
Hormone therapy (reduce level of androgens, used in combo w/ radiotherapy or alone if no cure possible) eg. androgen-receptor blockers, GnRH agonists, bilateral orchidectomy (remove testicles) - side effects: Hot flushes, Sexual dysfunction, Gynaecomastia, Fatigue, Osteoporosis
Surgery eg. radical prostatectomy

Question 16

wtf is benign prostatic hyperplasia? + symptoms

Answer 16

very common in older men (50+)
caused by hyperplasia/growth of stromal and epithelial cells of prostate
usually presents with UTI symptoms

symp:
Hesitancy, Weak flow, Urgency, Frequency, Intermittency, Straining to pass urine, Terminal dribbling, Incomplete emptying, Nocturia

Question 17

investigate BPH?

Answer 17

DRE
abdo exam
urinary frequency vol chart
urine dipstick
prostate-specific antigen testing
international prostate symptom score system

benign prostate = smooth, symmetrical, slightly soft, maintained central sulcus

Question 18

management BPH?

Answer 18

mild symptoms may not need intervention

Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms (treat immediate symp). can cause postural hypotension (falls on standing)

5-alpha reductase inhibitors (e.g., finasteride) gradually reduce the size of the prostate (treat enlargement). 5AR converts testosterone to DHT (more potent) hence inhibitors reduce DHT in tissues - can take 6 months to work. common side effect is sexual dysfunction

surgery:
Transurethral resection of the prostate (TURP) - most common, removal of part of prostate using resectocope in urethra and diathermy loop = creates a larger space for urine flow

Transurethral electrovaporisation of the prostate (TEVAP/TUVP) - resectoscope, tissue vaporised to create larger space

Holmium laser enucleation of the prostate (HoLEP) - rectoscope, laser prostate tissue

Open prostatectomy via an abdominal or perineal incision

Question 19

wtf is prostatitis? + complications

Answer 19

inflam of prostate classed as:
acute bacterial infection
- rapid onset of symptoms

chronic

• symp 3 months+
• subdivided into chronic bacterial infection and chronic prostatitis/chronic pelvic pain syndrome

complications:
sepsis, prostate abscess, acute urinary retention, chronic prostatitis

Question 20

presentation of prostatitis?

Answer 20

chronic, 3 months of:
pelvic pain, LUTS, sexual dysfunction, painful bowel movements, tender/enlarged prostate

acute bacterial: above symptoms plus fever, myalgia, nausea, fatigue, sepsis

National Institute of Health Chronic Prostatitis Symptom Index tests severity and impact on QOL

Question 21

investigate prostatitis and management?

Answer 21

urine dipstick to check for infection
urine microscopy, culture, sensitivities, chlamydia and gonorrhoea NAAT testing

manage:
acute = hospital admission, oral antibiotics eg. ciprofloxacin, analgesia, laxatives

chronic = alpha blockers eg. tamsulosin, analgesia, psychological treatment, antibiotics, laxatives

Question 22

wtf is testicular torsion?

bell clapper cause?

Answer 22

twisting of the spermatic cord with rotation of the testicle
urological emergency
delay could increase risk of ischaemia, necrosis, infertility
usually teenage boys, may be history of recurrent symptoms
triggered by activity eg. sport

bell clapper deformity:
Normally, the testicle is fixed posteriorly to the tunica vaginalis. this fixation is absent in this deformity
testicle hangs in a horizontal position (like a bell-clapper)
= It is able to rotate within the tunica vaginalis, twisting at the spermatic cord = cuts off the blood supply

Question 23

presentation testicular torsion eg. examination findings?

Answer 23

acute rapid onset of unilateral testicular pain
abdom pain, vomiting

Examination findings are:
Firm swollen testicle
Elevated (retracted) testicle
Absent cremasteric reflex
Abnormal testicular lie (often horizontal)
Rotation, so that epididymis (long coiled tube) is not in normal posterior position

Question 24

management of testicular torsion?

Answer 24

urgent treatment

Nil by mouth, in preparation for surgery
Analgesia as required
Urgent senior urology assessment
Surgical exploration of the scrotum
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

scrotal ultrasound can confirm the diagnosis - show the whirlpool sign, a spiral appearance to the spermatic cord and blood vessels
however must avoid wasting time

Question 25

wtf is nephritic syndrome?

Answer 25

group of symptoms, not a diagnosis Haematuria - microscopic (not visible) or macroscopic (visible). Oliguria - significantly reduced urine output. Proteinuria - protein in the urine less than 3g / 24 hours. Any more and it starts being classified as nephrotic syndrome. Fluid retention

Question 26

wtf is nephrotic syndrome?

Answer 26

way of saying “the patient has these symptoms”, which indicates there is an underlying disease present but doesn’t specify the disease ``` must fulfil the following criteria: Peripheral oedema Proteinuria more than 3g / 24 hours Serum albumin less than 25g / L Hypercholesterolaemia ```