Year 3 > Urological > Flashcards

Urological Flashcards

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1
Q

Describe Acute kidney injury

A

Acute decline in kidney function leading to dysregulation of fluid balance and electrolytes and retention of nitrogenous waste products

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2
Q

Risk factors of aki? (8)

A
  • Age >65 years
  • History of:
    • CKD
    • HF
    • Liver disease
    • Diabetes
    • Multiple myeloma
    • contrast administration
    • NSAIDs/ACEi’s or ARBs/Diuretics
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3
Q

What are the 3 types of AKI?

A

Prerenal
Intrinsic
Postrenal

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4
Q

Prerenal aki- what is this?

A

Any condition that leads to decreased renal perfusion → low urinary sodium

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5
Q

Causes of prerenal aki? (5)

A
  • Hypovolaemia- caused by what? (3)
    • Haemorrhage
    • Diarrhoea
    • Vomiting
  • Hypotension- caused by what? (3)
    • Shock
    • Sepsis
    • Anaphylaxis
  • Heart failure
  • Renal artery stenosis
  • Drugs- such as? (2)
    • NSAIDs
    • ACEis
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6
Q

Renal artery stenosis- investigation?

A

Magnetic resonance angiography (MRA)

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7
Q

What do we not give for bilateral renal artery stenosis?

A

ACEi as it will cause deterioration

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8
Q

Physiological feature of Renal artery stenosis

A

Asymmetrical kidneys

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9
Q

What is the serum urea:creatinine ratio in aki?

A

Raised

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10
Q

Intrinsic aki- what is this?

A

Any condition that leads to severe direct kidney damage → high urinary sodium

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11
Q

What is the most common form of AKI seen in clinical practice?

A

Acute tubular necrosis

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12
Q

What is Acute tubular necrosis

A

Damage to tubular cells due to ischaemia (shock or sepsis) or nephrotoxins (contrast or aminoglycosides)

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13
Q

Describe ischaemic acute tubular necrosis

A

Damage to tubular cells due to prolonged and severe ischaemia
- What can cause decrease in blood flow? (4)
- Shock
- Heart failure
- Renal artery stenosis
- Excessive GI fluid loss

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14
Q

Give examples of endogenous toxins that cause acute tubular necrosis (3)

A
  • Myoglobin from rhabdomyolysis (raised CK)
  • Uric acid from tumour lysis syndrome
  • Monoclonal light chains from multiple myeloma
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15
Q

Give examples of exogenous toxins that cause acute tubular necrosis (5)

A
  • Aminoglycosides like gentamicin
  • Cisplatin
  • NSAIDs
  • Contrast agents
  • Anti-freeze
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16
Q

What is seen on microscopy for Acute tubular necrosis?

A

Muddy brown granular casts in the urine

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17
Q

Describe urine sodium and osmolality for Acute tubular necrosis (2)

A
  • High urine sodium
  • Low urine osmolality
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18
Q

What is the most common drug-induced intrinsic cause of AKI?

A

Acute interstitial nephritis

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19
Q

Which drugs commonly cause Acute interstitial nephritis? (2)

A
  • Penicillin/antibiotics
  • NSAIDs
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20
Q

List systemic symptoms of Acute interstitial nephritis (4)

A
  • Fever
  • Arthralgia
  • Rash
  • Eosinophilia (Allergic type reaction → Type IV hypersensitivity)
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21
Q

What may you find on urinalysis of Acute interstitial nephritis?

A

White cell casts because an immune reaction is occurring

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22
Q

What may you find on urine dip of Acute interstitial nephritis?

A

Leukocytes +++

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23
Q

What may you find in bloods of Acute interstitial nephritis? (2)

A
  • Raised IgE
  • Eosinophilia
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24
Q

List types of vascular disease causing intrinsic AKI (2)

A

Haemolytic uraemic syndrome (HUS)
Thrombotic thrombocytopenia purpura (TTP)

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25
List Haemolytic uraemic syndrome (HUS) clinical features (3)
- Haemolytic (normocytic) anaemia - Jaundice - Schistocytes - Thrombocytopenia - Petechiae - Purpura - AKI following blood diarrhoeal illness - Due to shiga-toxin producing e.coli 0157:H7
26
What is the management for HUS?
Supportive
27
What is TTP?
Abnormally large and sticky multimers of von Willebrand’s factor cause platelets to clump within vessels
28
List clinical features of ttp (3)
- Overlap with HUS - Fever - Neurological signs - Headache - Confusion - Seizures
29
How is TTP managed? (2)
- Plasmapheresis - Rituximab
30
Name another intrinsic cause of AKI
Glomerulonephritis
31
What are the two different ways glomerulonephritis can present?
- Nephrotic syndrome - Nephritic syndrome
32
Postrenal aki- what is this?
Any condition that results in bilateral obstruction of urinary flow from renal pelvis to urethra
33
List causes of post renal AKI (4)
- Kidney stones - BPH - External compression of ureter e.g. due to tumour - Neurogenic bladder- due to? **(3)** - MS - Spinal cord lesions - Peripheral neuropathy
34
How is AKI staged?
KIDIGO criteria
35
Stage 1 KIDIGO criteria - meaning? (2)
- Creatinine rise of 1.5x compared to baseline OR - Urine output <0.5 ml/kg/hour for 6 hours
36
Stage 2 KIDIGO criteria - meaning? (2)
- Creatinine rise of 2x compared to baseline OR - Urine output <0.5 ml/kg/hour for 12 hours
37
Stage 3 KIDIGO criteria - meaning? (4)
- Creatinine rise of 3x compared to baseline OR - Urine output <0.3 ml/kg/hour for 24 hours OR - Anuria for 12 hours (lack of urine production) OR - Serum creatinine >354 μmol/dl
38
What are the clinical features of aki? (6)
- Decreased urine output → Oliguria (reduced urine output) or anuria (complete absence of urine output) - Signs of volume depletion (prerenal AKI) - Signs of fluid overload (Na+ and H2O retention) - Signs of uraemia (due to failure of kidneys to excrete urea) - Signs of renal obstruction (postrenal AKI)- - Arrhythmias, due to changes in electrolyte balance
39
Signs of volume depletion (prerenal AKI)- which are? **(5)**
- Hypotension - Tachycardia - Reduced skin turgor - Orthostatic hypotension - Thirsty
40
Signs of fluid overload (Na+ and H2O retention)- which are? **(4)**
- Peripheral or pulmonary oedema - Hypertension - HF - SOB
41
Signs of fluid overload (Na+ and H2O retention)- Signs of uraemia (due to failure of kidneys to excrete urea)- which are? **(5)**
- Anorexia - Nausea - Encephalopathy - Asterixis - Pericarditis
42
Signs of renal obstruction (postrenal AKI)- which are? **(3)**
- Distended bladder (suprapubic distension) - Incomplete voiding → Lower urinary tract symptoms - Pain over bladder or flanks
43
Arrhythmias, due to changes in electrolyte balance- such as? (specifically caused by AKI)
Hyperkalaemia - List features of hyperkalaemia **(2)** - Muscle weakness - Paraesthesia
44
What will investigations show in AKI? (3)
- Increase in serum creatinine - Decrease in urine output - Potassium increased- when is it considered severe? **(2)** - If K>6.5 OR - ECG changes-
45
what are hyperkalaemic ECG changes? **(3)**
- Tall tented T waves - Loss of P waves - Broad QRS complexes
46
What can you rule out if positive protein on urine dipstick? (2)
- Pre-renal and post-renal causes - Indicates intrinsic cause
47
What will acute ischaemic necrosis show as on a urine dipstick?
+++ leukocytes
48
What does glomerulonephritis cause on urine dipstick?
Positive blood
49
what do you do if after initial investigation no obvious cause of AKI can be found?
Renal ultrasound
50
Why is renal ultrasouns especially important to do if you suspect post-renal AKI?
To look for obstruction
51
What other investigation is important to do in suspected AKI?
ABG
52
What is the AKI management plan? (4)
- Stop nephrotoxic substances - Manage volume status - Treat Hyperkalaemia if ECG changes - Patient may require catheterisation if post-renal AKI
53
stop nephrotoxic substances- which are? **(4)**
DAMN - Diuretics - Aminoglycosides (gentamicin) & ACEi - Metformin if eGFR <45 - why? doesn’t worsen AKI but can accumulate and cause toxicity in the form of lactic acidosis - NSAIDs - What NSAID can be continued and when? Aspirin at cardio-protective doses i.e. 75mg to prevent cardiovascular events
54
Manage volume status- how do you do this in pre-renal AKI?
IV fluids (0.9% sodium chloride) if hypovolaemia (pre-renal) - What if they’re hypervolaemic? **(2)** - IV diuretics OR - Dialysis (or fluid restrict)
55
Treat Hyperkalaemia if ECG changes- how? **(2)**
- IV gluconate 10% 30mL to stabilise cardiac membrane - Insulin (Actrapid) to drive K+ into cells along with dextrose to prevent hypoglycaemia
56
What can be given to eliminate potassium from the body? | *For non-emergency or chronic hyperkalaemia*
Calcium resonium Given orally or rectally | *Binds K+ in the gut in exchange for Ca - faecal excretion*
57
How is the aki patient managed if they’re not responding to medical treatment?
Haemodialysis → renal replacement therapy
58
List indications for haemodialysis (4)
- Acidosis - Refractory hyperkalaemia (refractory meaning not responding to treatment) - Refractory pulmonary oedema - Uraemic complications e.g. pericarditis/encephalopathy
59
List complications of AKI (3)
- Hyperphosphataemia - Hyperkalaemia - Uraemia
60
What is Benign prostatic hyperplasia?
Benign glandular and stromal hyperplasia of the transitional zone of the prostate
61
What does the prevalence of histological BPH increase with?
Age
62
Describe the epidemiology of bph (2)
- 42% of men 51-60 affected - 82% of men 71-80 affected
63
Describe the aetiology of BPH (2)
- DHT is a potent prostatic growth factor - Androgen/oestrogen imbalance as men age
64
What is the difference between pathological and clinical BPH?
The presence of symptoms
65
Risk factors of bph? (2)
- >50 years old - Positive family history
66
Which drug is contraindicated in BPH and why?
Amitriptyline- can cause urinary retention | *mechanical explanation below*
67
how would prostatitis present? (4)
- Pain in perineum/penis/rectum/back - Obstructive voiding symptoms - Fever and rigors - DRE → tender, boggy prostate
68
Management of prostatitis? (2)
- Quinolone (e.g. ciprofloxacin) for 14 days - Screening for STI
69
What are the 2 main types of symptoms for bph?
Features of uncomplicated lower urinary tract symptoms (LUTS) - Voiding (obstructive) symptoms (often predominant symptom) - Storage (irritative) symptoms
70
Voiding (obstructive) symptoms (often predominant symptom)- what are they? **(6)**
SW HIPS - straining to urinate - weak stream - hesitancy (difficulty initiating urination) - intermittency - post-void dribbling - sensation of incomplete emptying
71
- Storage (irritative) symptoms- what are they? **(3)**
FUN - Frequency - Urgency - Nocturia
72
What does a fever with dysuria suggest?
Complicated UTI
73
What is the gold-standard investigation for bph?
Transrectal ultrasound-guided needle biopsy
74
What does urinalysis show in uncomplicated BPH?
Normal
75
what does pyuria (pus in urine) indicate in urinalysis for bph?
May indicate UTI
76
What may haematuria indicate in urinalysis for bph?
Cancer
77
What does an increased PSA in bph suggest?What can results guide?
Presence of underlying prostate cancer or prostatitis Treatment in men with LUTS
78
What is postvoid residual volume a measure of?
Urinary retention
79
What postvoid residual volume may be considered urinary retention?
>300 mL may be considered urinary retention
80
What does BPH feel like on DRE?
Smooth enlarged prostate, palpable midline groove
81
What conservative management is there for bph? (2)
- Monitor symptom progression (watchful waiting) - Lifestyle → avoid caffeine
82
What’s first line for bph?
- Drugs- which ones? **(2)** - First line is α1-blockers (Tamsulosin) - Second line is 5a-reductase inhibitors (Finasteride)-
83
α1-blockers (Tamsulosin)- how does it work?
Relax smooth muscle of bladder to decrease resistance to urinary flow
84
α1-blockers (Tamsulosin) Side effects? **(3)**
- Dizziness - Postural hypotension - May also cause retrograde ejaculation
85
5a-reductase inhibitors (Finasteride)- how does it work?
Reduced conversion of testosterone to DHT, which leads to reduced prostate growth
86
5a-reductase inhibitors (Finasteride) Side effects? **(4)**
- Diminished libido - ED - Gynaecomastia - Decreases levels of PSA
87
What if drugs don’t work for bph?
Transurethral resection of the prostate (TURP)
88
Transurethral resection of the prostate (TURP) side effects (4)
- Retrograde ejaculation- most common complication - TURP syndrome - Urethral stricture/UTI - Perforation of prostate
89
TURP syndrome- features? **(3)**
- Hyponatraemia - Fluid overload - Glycine toxicity
90
Prognosis of BPH managed with meds?
Mild symptoms usually well controlled with medications
91
Prognosis of BPH managed with surgery?
Most patients get significant relief from surgery
92
What type of cancer is the majority of bladder cancers?
Transitional cell carcinomas (Urothelial carcinoma
93
Risk factors for SCC? (2)
- Areas where schistosomiasis is endemic (Middle East) - Long term catheterisation (>10 years)
94
Describe the epidemiology of bladder cancer (2)
- M>F - >65 years
95
Other risk factors of bladder cancer? (4)
- Aniline dye - Pelvic radiation - Chronic UTIs - Positive family history for bladder cancer
96
Most important risk factor of bladder cancer?
Smoking → Biggest RF in the west
97
Which occupations are high risk for bladder cancer? (2)
- Painters - Hairdressers
98
What are the clinical features of bladder cancer? (3)
- Gross painless haematuria (macroscopic haematuria is common) - Dysuria → associated with aggressive bladder cancer (pain/burning during urination) - Urinary frequency and urgency
99
What is key to making a diagnosis to bladder cancer?
Cystoscopy and biopsy → visualises bladder tumours and enable pathological diagnosis
100
What is the 1st line bedside investigation to bladder cancer?
Urinalysis for haematuria
101
Which investigations are done for staging in bladder cancer? (2)
- Renal and bladder ultrasound- may see hydronephrosis due to tumour causing obstruction - CT/MRI abdomen and pelvis
102
What other scan do we do for bladder cancer and why?
CXR → check for lung metastases
103
What is the next step for a 60 year old with unexplained non-visible haematuria and either dysuria or a raised WCC on a blood test?
Should be referred using the suspected cancer pathway within 2 weeks
104
How is non-muscle invasive and low risk bladder cancer managed?
Transurethral resection of bladder tumour (TURBT)
105
How is muscle invasive (T2 disease) bladder cancer managed?
Radical cystectomy → Removal of bladder, prostate and seminal vesicles
106
How is metastatic bladder cancer disease managed?
Palliative systemic chemotherapy
107
What is the survival rate for non invasive bladder cancer disease?
high
108
What is the survival rate for bladder cancer metastatic disease?
12%
109
What is prostate cancer?
A malignant tumour of glandular origin (adenocarcinoma), situated in the prostate
110
How common is the prostate cancer?
2nd most common cancer
111
Where does prostate rank as a cause of cancer mortality?
5th leading cause of cancer mortality in men worldwide
112
prostate cancer Risk factors? (4)
- Age >50 years - Family history - Black African ethnicity - BRCA 1 & 2
113
What are the clinical features of prostate cancer? (3)
- Typically asymptomatic - May present with complicated LUTS - Abnormal DRE
114
complicated LUTS- features? **(4)**
- Urinary retention - Haematuria - Incontinence - Flank pain
115
Abnormal prostate cancer DRE- features? **(4)**
- Asymmetrical - Hard - Nodular enlargement of prostate - Loss of midline sulcus
116
Advanced prostate cancer features? (5)
- Fatigue - Weight loss - Bone pain - Neurological deficits - Lymphoedema
117
What is now the first line investigation for prostate cancer?
Multiparametric MRI
118
What is the gold standard investigation for prostate cancer?why
Transrectal ultrasound-guided needle biopsy - May detect adenocarcinoma - Gleason staging
119
What antigen can you measure to detect prostate cancer?
psa
120
What is the issue with PSA levels?
Not cancer-specific → elevated in benign conditions - BPH - UTI - Prostitis
121
At what psa level is prostate cancer likely?
PSA >4 ng/mL
122
What physical exam can you perform for prostate cancer?
DRE
123
Why may you do a bone scan for prostate cancer?
Check for metastases
124
What will be raised if there are bone mets?
ALP
125
Which investigations can help stage cancer?
Pelvic CT/MRI scan
126
Why would you do an MRI spine in prostate cancer?
Look for metastases causing spinal cord compression → can lead to incontinence and weakness
127
What is the grading system for prostate cancer?
Gleason score
128
What does a low gleason score mean?
Better prognosis
129
What is the management plan for localised prostate cancer?
Active monitoring and watchful waiting
130
What does localised advanced prostate cancer score on the Gleason staging system?
T3/T4
131
What is the management plan for localised advanced prostate cancer? (2)
- Radical prostatectomy - Radiotherapy
132
Radical prostatectomy- what is a common complication?
ED
133
Radiotherapy- what does this increase risk of?
Bladder, colon and rectal cancer
134
What is the management plan for metastatic prostate cancer? (3)
Hormonal therapy - GnRH agonists- such as? Goserelin - Androgen antagonists- such as? **(2)** - Bicalutamide - Enzalutamide - GnRH antagonists- such as? Degarelix
135
side effects of GnRH agonist Goserelin (4)
- Gynaecomastia - Decreased libido - ED - Infertility
136
- What can initial treatment of Goserelin cause?
Tumour flare → bone pain, bladder obstruction
137
- How can we prevent tumour flare in goserelin treatment? **(2)**
- Give cyproterone acetate - Pretreatment with flutamide
138
What is Nephrotic syndrome?
Collection of signs and symptoms indicating damage to the glomerular filtration barrier
139
What is nephrotic syndrome characterised by? (3)
- Massive proteinuria - Hypoalbuminaemia - Oedema
140
5 causes of nephrotic syndrome
- Minimal change disease (primary) Membranous glomerulonephritis (primary) Focal segmental glomerulosclerosis (primary) Diabetic nephropathy (secondary) Amyloid nephropathy (secondary)
141
In which group is Minimal change disease the most common cause?
In children
142
What does Minimal change disease commonly present with?
Peri-orbital oedema
143
What diseases is Minimal change disease associated with? (2)
- URTI - Non-hodgkin’s lymphoma
144
Describe the pathophysiology of Minimal change disease
Cytokine mediated damage of podocytes (role is to prevent protein entering filtrate)
145
What will light microscopy show in Minimal change disease?
Normal
146
What will electron microscopy show in Minimal change disease?
Fusion of podocytes
147
What is the cause of Minimal change disease?
Often idiopathic
148
How is Minimal change disease managed?
Prednisolone (corticosteroids)
149
What if resistant to pred in Minimal change disease ?
Cyclophosphamide
150
In which group is Membranous glomerulonephritis the most common cause?
Most common cause in adults
151
Describe the pathophysiology of Membranous glomerulonephritis
Deposition of immune complexes on basement membrane
152
What diseases is Membranous glomerulonephritis commonly associated with? (4)
- Malignancy - SLE - Hep B & C - Autoimmune disease
153
What would a renal biopsy for Membranous glomerulonephritis show under light microscopy?
BM thickening
154
What would a renal biopsy for Membranous glomerulonephritis show under electron microscopy?
Spike and dome appearance
155
Which antibodies is Membranous glomerulonephritis associated with?
Anti-phospholipase A2 receptor antibodies
156
What other blood result may we see for Membranous glomerulonephritis ?
Low T4
157
How is the response of Membranous glomerulonephritis to steroids?
Low response to steroids
158
in which group isFocal segmental glomerulosclerosis most common?
Common in Afro Caribbean population
159
- Describe the pathophysiology of Focal segmental glomerulosclerosis
Sclerosis of glomeruli leads to damage and loss of podocytes
160
What would renal biopsy of Focal segmental glomerulosclerosis show on light microscopy?
Segmental areas of mesangial collapse and sclerosis
161
What would renal biopsy of Focal segmental glomerulosclerosis show on electron microscopy?
Effacement of foot processes of podocytes
162
What is Focal segmental glomerulosclerosis associated with? (5)
- Obesity - Diabetes - HIV - Heroin use - Sickle cell
163
How is Focal segmental glomerulosclerosis managed?
Corticosteroids
164
What additional signs do you usually see in Diabetic nephropathy? (2)
- Retinopathy - Neuropathy
165
What will you find in urine in Diabetic nephropathy? | *apart from glucose*
Microalbuminuria
166
What will you find on light microscopy for Diabetic nephropathy? (3)
- Mesangial expansion - GBM thickening - Kimmelstiel-Wilson nodules
167
What about on kidney USS in early stages of Diabetic nephropathy?
Enlarged kidneys → unlike other causes of kidney disease
168
What other kidney diseases cause enlarged kidneys? (3)
- Autosomal dominant polycystic kidney disease - Amyloidosis - HIV associated nephropathy
169
How is diabetic nephropathy managed? **(2)**
- Diabetic control - ACEi/ARB
170
In which group of people is Amyloid nephropathy most commonly seen?
elderly patients
171
What diseases is Amyloid nephropathy associated with? (2)
- Multiple myeloma - Chronic inflammatory disease e.g. TB, RA
172
What is the most commonly affected organ in systemic amyloidosis?
Kidney → Deposition of amyloid in kidney
173
What will congo red staining show inAmyloid nephropathy ?
Apple-green birefringence - **Clinical features**
174
Other symptoms of amyloidosis? (3)
- Breathlessness - Weakness - Can cause hepatosplenomegaly
175
Clinical features of nephrotic syndrome (6)
- Massive Proteinuria >3.5g/24 hours → may cause foamy urine - Oedema → starts with periorbital oedema, then may lead to peripheral oedema (or pulmonary oedema) - Hypoalbuminaemia (<25 g/L) - Hyperlipidaemia → Low blood protein increases lipid synthesis - Hypercoagulable state - Increased Risk of Infection
176
Hypercoagulable state in nephrotic syndrome- why?what does this increase risk of?
Due to loss of antithrombin III (also protein C and protein S) and rise in fibrinogen levels increased risk of thrombosis
177
Increased Risk of Infection in nephrotic syndrome- how?
Due to loss of immunoglobulins
178
What does urine dipstick showin nephrotic syndrome?
+++ proteins (or more)
179
What does 24-hour urine protein showin nephrotic syndrome?
>3.5g/24 hours
180
What does urine sediment microscopy showin nephrotic syndrome?
Fatty casts
181
Describe serum albumin levelsin nephrotic syndrome
low
182
Describe cholesterol levels in nephrotic syndrome
high
183
How is the oedema managed in nephrotic syndrome? (3)
- Dietary sodium restriction - Fluid restriction - Diuretic therapy (furosemide)
184
How is the proteinuria managed?
RAAS inhibitors - ACEi’s (ramipril) - ARBs (Losartan)
185
What is given as prophylactic anticoagulation? (2)
- LMWH - Warfarin
186
How is the infectious risk managed in nephrotic syndrome?
Vaccinations
187
Complications of nephrotic syndrome? (3)
- Infection due to urinary loss of immunoglobulins - VTE due to urinary loss of antithrombin - Hyperlipidaemia due to increased hepatic production of lipids to restore the serum oncotic pressure
188
Who is Testicular cancer common among?
in young adult men → 20-34 years old
189
What is the common type of Testicular cancer?
Seminomas
190
What are the other types of Testicular cancer? (2)
- Non-seminoma tumours (teratomas) - Non-germ cell tumours
191
Risk factors of Testicular cancer? (3)
- Cryptorchidism (undescended testes) - Infertility - Age <45
192
What are the Clinical features of testicular cancer? (6)
- Painless unilateral hard nodular testicular mass - Negative transillumination test (light does not shine through) - Gynaecomastia - May be associated hydrocele - Lymphadenopathy - Metastatic Disease
193
Metastatic Disease in testicular cancer- features? **(4)**
- cough - SOB - chest pain - Bone pain (backache)
194
Gynaecomastia in testicular cancer- why?
Due to seminoma secreting hCG ****(increased oestrogen:androgen ratio)
195
Which lymph nodes does testicular cancer typically spread to?
Para-aortic lymph nodes
196
How will a hydrocoele differentiate from testicular cancer? (3)
- Transilluminates - Not separate to testis - Fluctuant
197
What is the first line principal test for testicular cancer?
Ultrasound with colour doppler of testis → shows testicular mass
198
Which tumour markers can you check for in testicular cancer? (3)
- Alpha fetoprotein - Beta-hCG - LDH
199
How would you stage testicular cancer? (2)
Look for mets: - CXR - CTAP
200
What will tumour markers show in seminoma? (3)
- normal AFP - Raised beta-hCG sometimes - Raised LDH sometimes
201
What will tumour markers show in non-seminoma germ cell? (3)
- Raised AFP - Raised Beta-hCG - Normal LDH
202
How would you manage the testicular cancer patient prior to surgery?
Sperm cryopreservation → Tumours are associated with decreased fertility
203
What is the surgical removal of the testicular tumour called?
Radical inguinal orchidectomy
204
How else is the testicular cancer patient managed? (2)
Radiotherapy and chemotherapy
205
Complication of testicular cancer?
infertility
206
What is the prognosis of testicular cancer like?
Excellent → High cure rate and 5 year survival rates of >95%
207
Define testicular torsion
Sudden twisting of the spermatic cord- surgical emergency
208
How does Testicular torsion cause an issue?
Results in venous outflow obstruction from testicle, progressing to arterial occlusion and testicular infarction
209
What is the peak incidence of Testicular torsion?
In first 30 days of life and during puberty (10-18 years old)
210
What are the most common causes of testicular torsion? (2)
- Bell clapper deformity (horizontal lie of the testes) - Cryptorchidism (undescended testes)
211
What are the 2 types of testicular torsion?
- intravaginal torsion- most common- twisting within the tunica vaginalis - Extravaginal torsion- usually in neonates
212
When does testicular torsion become peakkk?
Irreversible damage occurs after 6-12 hours of torsion
213
What are the clinical festures of testicular torsion? (7)
- Sudden onset severe unilateral testicular pain - Swollen and tender scrotum - High-riding testicle - Absent cremasteric reflex- diagnostic for testicular torsion - Negative Prehn sign- - Nausea and vomiting - Abdo pain
214
Negative Prehn sign- what is it?What diseases does this distinguish between?
No pain relief on elevation of testes Testicular torsion and epididymitis
215
High-riding testicle- what is this?
Affected testicle may appear higher than unaffected
216
Absent cremasteric reflex- diagnostic for testicular torsion- what is this?
Elevation of the testicle and scrotum in response to stroking of the ipsilateral inner thigh
217
What is first line investigation for testicular torsion?
Duplex US of scrotum-
218
Duplex US of scrotum- what does it show for testicular torsion? (4)
Don’t delay surgery, only do if diagnosis in doubt - Enlarged scrotum - Twisting of spermatic cord - Reduced/absent blood flow to/from affected testes - Whirlpool sign (spiral like pattern)
219
What is first line for testicular torsionand when do we give it?
Emergency scrotal exploration (radical inguinal orchidopexy) → ideally within 6 hours of symptom onset, untwists the affected testis Both testes should be fixed
220
What other investigations (inc. bloods) do we do for testicular torsion and why? (3)
Urinalysis, FBC, CRP → rule of epididymitis (should all be normal in testicular torsion)
221
When must treatment be done for testicular torsion?
6 hours of symptoms onset to save testes
222
What is second line for testicular torsionand when do we give it?
Manual testicular detorsion → if surgery not available in 6 hours or attempted prior to surgery for pain relief
223
What other management is there for testicular torsion?
Pain relief (morphine)
224
What do we do if it’s intermittent testicular torsion?
Refer for consideration of orchidopexy
225
Complications for testicular torsion (4)
- infarction of testicle - infertility due to loss of testicle - cosmetic deformity - recurrent torsion
226
Prognosis for testicular torsion
from onset, testicle may only survive up to 6 hours. Most testicles salvaged with prompt surgical intervention (quicker the surgery is performed, better the prognosis is)
227
What is epididymitis?
Inflammation of the epididymis (cord that connects the testis with ductus deferens), usually as a result of an infection
228
Causes of epididymitis? (2)
uti sti
229
UTI- which groups is it more common in? (2)
older men and children
230
What is the most common causative agent of sti?
e coli
231
STI- which group is it more common in?
Young males <35 years
232
What are the most common causative agents of sti? (2)
- Chlamydia trachomitis is no 1 - Neisseria gonorrhoeae is no 2
233
What is orchitis?
Inflammation of the testis
234
List risk factors for epididymitis & orchitis (6)
- Unprotected sexual intercourse - Bladder outflow obstruction - UTIs - Immunosuppression - Vasculitis - Mumps
235
Mumps features? (4)
- fever - malaise - muscular pain - parotitis (earache or pain on eating)
236
- How is mumps prevented?
MMR vaccine Notifiable disease
237
- Complications of mumps? **(2)**
orchitis and pancreatitis
238
Testicular torsion- features? (4)
- age <20 yrs - severe pain - more acute onset - -ve prehn sign
239
What are epididymitis features? (5)
- Unilateral scrotal pain and swelling, develops over several days and radiates to the ipsilateral flank - Tenderness along posterior testis - Positive Prehn sign (pain relief on elevation of the testes) - Hot, erythematous, swollen hemiscrotum - Low grade fever
240
Positive Prehn sign (pain relief on elevation of the testes)- what is it -ve in?
Testicular torsion
241
What is there a history of in Epididymitis & orchitis? (2)
- Symptoms of lower UTI (dysuria, frequency, urgency) - Symptoms of STI (penile discharge)
242
What are orchitis features? (3)
- Sudden onset of nausea & vomiting - Sudden fever - Swollen and tender testicle(s) although primarily unilateral
243
Why would you do a urinalysis for Epididymitis & orchitis?
To identify pyuria or bacteriuria
244
What investigation would be done to identify the causative agent for epididymitis & orchitis in Sexually active younger adults?
NAAT for STIs
245
What investigation would be done to identify the causative agent for epididymitis & orchitis in Older adults with low risk sexual history?
Urine culture (MSU for MC&S)
246
What investigation would be donefor epididymitis & orchitis to rule out the most important differential diagnosis?
Duplex ultrasound of the scrotum → rule out testicular torsion
247
Describe symptomatic management of epididymitis & orchitis (4)
- NSAIDs - Application of cold pack - Bed rest - Scrotal elevation
248
How would you treat the infection in epididymitis & orchitis ?
Start empiric antibiotic treatment based on the most likely causative organism and adjust antibiotic therapy once causative organism is identified
249
What antibiotics are most commonly used in epididymitis & orchitis and when? (3)
- Doxycycline if <35, it covers chlamydia - Ciprofloxacin if >35 - which patient should we avoid this in? Patients with epilepsy - Ceftriaxone if gonorrhoea suspected
250
What is empiric treatment in epididymitis & orchitis ? (2)
ceftriaxone 500mg intramuscularly single dose, plus oral doxycycline 100mg twice daily for 10-14 days
251
What is the prognosis of epididymitis like?
Symptoms usually resolve rapidly following the initiation of appropriate antibiotic therapy
252
Name a complication of epididymitis
Epididymo-orchitis → Spread of infection from epididymis to the testicle
253
What is the most common complication of mumps?
Orchitis
254
Name complications of orchitis (2)
- Atrophy - Hypofertility
255
What is urinary incontinence?
Common condition characterised by uncontrollable leakage of urine
256
Which group of people is urinary incontinence most common in?
Elderly females
257
Neurological causes of urinary incontinence? (2)
- Multiple sclerosis - Spinal injury
258
Genitourinary causesof urinary incontinence? (4)
- Trauma to pelvic floor - Sphincter deficiency - Bladder outlet obstruction - Pelvic floor weakness
259
Reversible causes of urinary incontinence? (2)
- Diuretics - UTIs
260
Risk factors for urge incontinence? (4)
- Advancing age - High BMI - Smoking - Caffeine
261
Risk factors for stress incontinence? (2)
- Vaginal childbirth - Hysterectomy
262
What is stress incontinence?
Leaking small amounts when coughing, laughing or sneezing (activities that increase intra-abdominal pressure)
263
What is urge incontinence?
Over-active bladder - Overactivity of detrusor muscle, leads to strong, sudden sense of urgency, followed by involuntary leakage
264
What is mixed incontinence?
Combo of stress and urge incontinence
265
What is overflow incontinence?
Due to bladder outlet obstruction, overdistended bladder due to urinary retention causing leakage (e.g. due to prostate enlargement)
266
Name other drug causes of urinary retention (2)
- TCA (amitriptyline) due to cholinergic effect - Opioids
267
List signs of urinary retention (3)
- Palpable bladder - Suprapubic tenderness - Delirium in elderly patients
268
Why are bladder diaries completed?
To assess frequency and volume of micturition
269
How long should bladderdiaries be completed for a minimum of?
3d
270
What examination excludes pelvic organ prolapse? What else does this examination allow you to assess?
Vaginal exam The ability to initiate voluntary contraction of pelvic floor muscles
271
Why is urine dipstick and culture done for urinary incontinence?
To exclude UTI
272
What investigation is requested for suspected bladder outflow obstruction? What do they show? (2)
Urodynamic studies - Increased detrusor pressure - Reduced urine flow rate
273
What is diagnostic for acute urinary retention?
Bladder ultrasound
274
what can identify urinary retention on ultrasouns?
Postvoid residual volume
275
What signifies chronic high pressure urinary retention on ultrasound?
if renal function is impaired or if there is hydronephrosis → typically due to bladder outflow obstruction
276
What signifies chronic low pressure urinary retention on ultrasound?
normal renal function and no hydronephrosis
277
Lifestyle modifications for urinary incontinence? (3)
- Weight loss - Diet changes (decrease alcohol and caffeine) - Smoking cessation
278
What is 1st line for stress incontinence?
Pelvic floor muscle training
279
Surgery for stress incontinence?
Retropubic mid-urethral tape procedure
280
Medication for stress incontinence?
Duloxetine (Combined noradrenaline and serotonin reuptake inhibitor)
281
What is 1st line for urge incontinence?What is the aim?
Bladder retraining → Lasts for minimum of 6 weeks To increase the intervals between voiding
282
Name a bladder stabilising drug for urge intolerance
Antimuscarinics (Oxybutynin)
283
Complications of urinary incontinence? (4)
- depression - Psychological stress - Dermatitis/skin infections (from prolonged contact with urine) - UTIs
284
What other pathology can urinary retention lead to?
AKI
285
What is nephrolithiasis?
Presence of crystalline stones (calculi) within the urinary system (kidneys and ureter)
286
Describe the epidemiology of nephrolithiasis(2)
- M>F - 45-70 years old
287
Risk factors of nephrolithiasis? (6)
- Dehydration - High salt intake - White ancestry - Male - Obesity - Crystalluria
288
What different types of crystalline stones are there? (4)
- Calcium oxalate (most common, 75%) Struvite (15%) Uric acid (5%) Cysteine (1%)
289
How do calcium oxalate appear on x-rays/CT scans?
Radio-opaque (White)
290
What do Calcium oxalate do to urine pH?
Acidify
291
Name a risk factor for calcium oxalate stones
Hypercalciuria
292
How do Struvite appear on x-rays/CT scans?
White
293
What do Struvite do to urine pH?
Alkalizes
294
What can Struvite form into?
Staghorn calculi
295
Name a predisposing factor of Struvite?
Recurrent UTIs (Chronic proteus infection)
296
How do Uric acid appear on x-rays/CT scans?
radiolucent → Black (not visible)
297
What condition are uric acid associated with?
Gout/hyperuricaemia
298
When do calculi become symptomatic?
Asymptomatic until they get stuck
299
Clinical features of urinary tract calculi? (5)
- Renal colic → severe, acute flank pain that radiates to the groin (loin to groin pain) that may be colicky - N&V - Urinary frequency/urgency - Haematuria (85% microscopic) - Testicular pain
300
What is 1st line bedside test for renal calculi?What will it show?
Urine dipstick May show microhaematuria
301
What is the gold standard for Urinary tract calculi? When should you do this? Who do we not do this on?
Non-contrast CT KUB Within 24 hours of presentation Pregnant women
302
What can Non-contrast CT KUB show for Urinary tract calculi? (2)
calcification in renal collecting system or ureter
303
What can Non-contrast CT KUB show for hydronephrosis
Dilatation of the renal pelvis, calyces, and/or proximal ureter due to a distal obstruction to the outflow of urine
304
What may the patient require for Urinary tract calculi
Nephrostomy as decompression
305
What investigation will you do for Urinary tract calculi if it a pregnant patient or a child?
Renal ultrasound
306
Why is an X-ray important for Urinary tract calculi ?
Visible stone on x-ray is necessary for the use of ESWL (extracorporeal shockwave lithotripsy)
307
What does acute management for Urinary tract calculi involve? (3)
- Hydration - Analgesia (NSAIDs) → IM diclofenac - Anti-emetics
308
What is the management for a Urinary tract calculi <5mm?What can you prescribe if the stone is in the distal ureter?
Will pass spontaneously Alpha blocker (Tamsulosin)
309
What is the management for Urinary tract calculi >10mm? (3)
- 1st line is extra corporeal shock wave lithotripsy - Ureteroscopy - Percutaneous nephrolithomy
309
- What if Urinary tract calculi <5mm stone does not pass after 4-6 weeks?
Surgery
310
extra corporeal shock wave lithotripsy- what is this?
Non-invasive method enabling stone fragmentation using an acoustic pulse
311
ureteroscopy- what is this?When would this be done rather than lithotripsy?
Ureteroscope passed retrograde through the ureter and into the renal pelvis to remove or destroy stones Pregnant patients
312
Percutaneous nephrolithotomy- what is this? - When would you do this? **(2)**
Minimally invasive keyhole surgery through the back to retrieve stones - Staghorn calculi (struvite) OR - >20mm
313
What is the management for calcium stones?
Thiazide diuretics → cause hypercalcaemia, meaning less calcium is excreted in urine
314
How are uric acid stones treated?
Allopurinol
315
What is the management for an infected or obstructed system (AKI/sepsis/hydronephrosis)? (2)
surgical decompression (Nephrostomy) and IV Abx
316
What do we do in a patient with a long term suprapubic catheter that has a blockage?
Do cystoscopy → blockage may be due to blood clots or stones
317
Name a complication of urinary tract calculi
Recurrent UTIs (risk of pyelonephritis or urosepsis)
318
What is a UTI?
Infection of the bladder, urethra, ureters or kidneys that are most commonly caused by bacteria
319
Name a common causative agent of uti
E.coli (gram negative bacilli)
320
What is the difference between lower UTIs and upper UTIs?
- Bladder & urethra are lower UTIs - Kidneys & ureters are upper UTIs
321
why are females at higher risk of UTIs?
Women have shorter urethra (hence shorter distance to bladder from urethral opening) and anal and genital regions that are closer in proximity, hence at higher risk of contracting UTI
322
Risk factors of uti? (6)
- Abnormalities of urinary tract (BPH, kidney stones etc.) - Pregnancy - Postmenopause - Sexual intercourse - Urinary catheters - Anything causing urine stasis
323
List clinical feature of lower UTI (e.g. urethritis, cystitis) (5)
- Dysuria - Urinary frequency & urgency - Malodorous urine - Haematuria - Suprapubic tenderness (lower abdo pain)
324
List clinical features of upper UTI (4)
- Fever - Fatigue - Flank pain - N&V (may have pyelonephritis)
325
List clinical features of acute pyelonephritis (4)
- Flank (loin) pain and fever - Rigors and vomiting - White cell casts in urine - May lead to haemodynamic instability
326
List distinguishing features of acute pyelonephritis from cystitis (3)
- Pyrexia - Flank/loin pain & tenderness - Abnormal vital signs
327
What other features may elderly patients have for uti? (2)
- Delirium - Acute confusion
328
What is the first line, most important initial diagnostic test for uti?What will you find? (2)
Urine dipstick Positive leukocytes and nitrites
329
What investigation do you do in women with suspected UTI with haematuria?What further step do we take with pregnant women?
Send MSU for culture along with treating UTI Repeat MSU once symptoms have resolved to see if UTI has actually gone
330
What is the gold standard investigation for uti?
MSU should be sent for MC&S to identify bacteria
331
What will be seen in msu for pyelonephritis?
White cell casts
332
Why do you do a urine culture for uti?
Determine causative pathogen and adapt antibiotic treatment
333
What does E.coli appear like on MacConkey agar?
Intensely pink → Positive lactose fermentation
334
What antibiotics do you prescribe for uncomplicated lower UTI? (2) How long is the prescription? (2)
- Nitrofurantoin OR - Trimethoprim - Women have a 3 day prescription (7 day if pregnant) - Men have a 7 day prescription → send urine culture too for all cases
335
What is 2nd line antibiotics for uti?
Beta-lactam antibiotics (amoxicillin) or cefalexin
336
When should trimethoprim be avoided?
First trimester of pregnancy → it’s a folate antagonist
337
When should nitrofurantoin be avoided?
Near the end of pregnancy → risk of haemolytic anaemia in baby
338
How do you manage asymptomatic bacteriuria in catheterised patients?What if it is symptomatic?
Don’t treat (could be colonisation of the catheter) 7 day Abx course and change catheter
339
How is asymptomatic bacteriuria managed in pregnant women?
Still treat with nitrofurantoin (avoid near term) or amoxicillin to avoid risk of progression to pyelonephritis
340
How is acute pyelonephritis managed? (2)
- Hospital admission - Broad spectrum cephalosporin (e.g. ceftriaxone/cefuroxime) or a quinolone (e.g. levofloxacin/ciprofloxacin) for 10-14 days
341
Name a complication of UTI
Pyelonephritis
342
What is CKD
Abnormality of kidney structure or function (GFR <60 mL/minute/1.73m^2) that is present for ≥3 months
343
risk factors of ckd(7)
- Diabetes - Hypertension - Obesity - Advanced age - Substance use - AKI - Black or Hispanic ethnicity
344
Causes of ckd? (4)- Which is the most common genetic cause?
- Diabetic nephropathy - Hypertensive nephropathy - Glomerulonephritis - Polycystic kidney disease - Autosomal dominant - Screen relatives with abdominal US
345
What are clinical features of CKD mainly manifestations of? (3)
- Uraemia → Lack of excretion of toxic substances - Anaemia → Lack of EPO produced by kidney - Hyperphosphataemia → Lack of excretion of toxic substances
346
List clinical features of CKD (7)
- Often asymptomatic → may be finding of routine blood test or urine test - Fatigue - Oedema (Peripheral/Pulmonary) due to Na/H2O retention - Nausea - Pruritus due to uraemia - Hypertension - Symptoms of Hypocalcaemia (due to 1-alpha-hydroxylase deficiency)- which are? **(4)** - Muscle twitching - Arrhythmias - Tetany - Paraesthesia
347
What can indicate if kidney injury is chronic and not acute?
Hypocalcaemia
348
What will renal profile show for ckd? (2)
- Elevated creatinine - Electrolyte abnormalities (hyperkalaemia)
349
What is GFR for ckd?When is GFR not a good measurement?
<60 mL/minute/1.73 m^2 If someone has a high muscle mass due to the increased creatinine
350
What will urinalysis show for ckd? (2)
Haematuria and/or proteinuria
351
What is an ACR used for?
To check for proteinuria
352
What is key for management of proteinuria?
ACEi
353
What happens to urinary albumin in CKD?
Increased
354
What is 1st line imaging for kidney structure?What does it show in CKD?
Renal ultrasound Small kidneys
355
what calcium/phosphate/PTH levels would we see for ckd? (4)How is it managed? (2)
- Low calcium - High phosphate - High PTH - Low vitamin D - Give vitamin D supplement (alfacalcidol) - Reduce dietary intake of phosphate or prescribe a phosphate binder (sevelamer)
356
What’s involved in a renal screen?
- Myeloma screen - what does this include? **(4)** - serum protein electrophoresis - serum free light chains - immunoglobulins - urine Bence jones proteins - Hep B/C/HIV - Immune panel - including? **(6)** - ANA - RF - Anti dsDNA - ANCA - anti GBM - complement - CK
357
How are stages ckd G1-G2 managed? (3)
- ACE inhibitor or ARB - Lisinopril if ACR >30 - Losartan - Dapagliflozin (SGLT2 inhibitor) - Statin
358
How are stages ckd G3-G4 managed? (3)
- ACEi - Dapagliflozin - Statin
359
How are stage ckd G5 (kidney failure) or uraemic patients managed? (2)
- 1st line is dialysis → Haemodialysis or peritoneal dialysis - 2nd line is kidney transplant
360
How does peritoneal dialysis work?
Filtration occurs in patient’s abdomen and can be done at home
361
Haemodialysis or peritoneal dialysis- which is more common?
Haemodialysis → regular filtration of blood through dialysis machine in hospital 3/4x a week
362
- What organism is the most common cause of peritonitis in peritoneal dialysis?
Staph epidermidis
363
kidney transplant- if patient gets ill soon after, what is the most likely cause?
Cytomegalovirus
364
- What other condition can the immunosuppressives e.g. ciclosporin taken after kidney transplant cause?
Squamous cell carcinoma of skin
365
List other principles of management of CKD (4)
- fluid and salt restrictions to maintain fluid balance - EPO-stimulating agents - Vitamin D supplements → Alfacalcidol (doesn’t require activation in kidneys) - Reduce dietary intake of phosphate or phosphate binders (sevelamer or alendronic acid) → **try dietary intake reduction first**
366
How do we manage iron deficiency in CKD?
correct it with ferrous sulphate first then give EPO stimulating agent (ESA)
367
Complications of ckd? (6)
- metabolic acidosis (inability to excrete acid) - hyperkalaemia - anaemia - renal osteodystrophy (elevation in PTH due to hypocalcaemia) - cardiovascular disease - pulmonary oedema
368
Describe the prognosis of CKD (2)
- Mostly progressive and leads to end-stage renal disease and the need for renal replacement therapy - Can’t be cured, but can be controlled and managed
Year 3
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