1
Q
Main functions of the kidneys?
A
- To eliminate waste material
- To regulate volume and composition of body fluid
- Endocrine function - EPO, renin, vit D in active form
- Autocrine function - endothelin, prostaglandins, renal natriuretic peptide
2
Q
Why can’t hypotensive or hypovolaemic patients excrete hydrogen and potassium ions?
A
If renal perfusion or glomerular filtration fall, reabsorption of water and sodium by the proximal tubules increases so minimum fluid reaches the distal tubule- which is where potassium and hydrogen are excreted.
3
Q
Define dysuria
A
Pain on micturition
4
Q
Define polyuria
A
Excessive urine output of greater than 2.5-3L in 24 hours. Must be differentiated from urinary frequency and nocturia.
5
Q
Define nocturia
A
Night-time urination
6
Q
Define oliguria- what are the causes?
A
Low urine output
Caused by AKI or urinary tract obstruction
7
Q
What are the most common causes of polyuria?
A
- Drink too much (polydipsia)
- Poorly controlled diabetes mellitus (solute diuresis)
- CKD
- Diabetes insipidus
8
Q
Why and how does diabetes insipidus cause polyuria?
A
There is a lack of vasopressin produced by the hypothalamus (stored in pituitary), meaning kidneys fail to concentrate urine and a lot of fluid is lost.
9
Q
What are the most common causes of nocturia?
A
- Drinking too much (polydipsia) especially before bed
- Prostatic enlargement (in men over 50)
- Congestive cardiac failure - lying down
- Sleep apnoea
10
Q
How can congestive cardiac failure cause nocturia?
A
Oedema around legs and ankles when lie down there is lack of gravity and can go to heart and expand atria. This causes the release of ANP which in turn increases production of urine.
11
Q
If man has benign prostatic enlargement, what 3 symptoms are they most likely to complain of?
A
- Nocturia
- Hesistancy
- Weak stream
12
Q
What are the 3 classes of lower urinary tract symptoms and give examples of each
A
- Storage e.g. urgency, nocturia
- Voiding e.g. weak stream, hesistancy, intermittency
- Post-micturition e.g. dribbling
13
Q
What 3 factors when taking a urology history would be red flags?
A
- Haematuria
- Pain
- Neurological deficit
14
Q
What four things would you look out for in examination of 55 yo male with BOO?
A
- Bladder palpable? - Chronic urinary retention
- Urethral meatus stenosis?
- Phimosis
- Size of prostate and malignant feel?
15
Q
How would an oliguric patient be managed (in 3 steps)?
A
- Exclude obstruction - pass catheter into bladder and large volume of urine released. If patient already catheterised, flush with saline to remove potential blockage
- Assess for hypovolaemia - if obstruction is excluded measure blood pressure, pulse, JVP, urinary electrolytes - urine output in response to fluid challenge is measured if hypovolaemic
- Management of established AKI - once above causes excluded
16
Q
What measurement is the best indicator of kidney function and how it is measured?
A
GFR (worked out by creatinine clearance)
17
Q
What tests can be done in urology to find or investigate underlying pathologies?
A
- Urinary tests - dipstick testing, urinary flow rate, post-void bladder residual
- Blood tests - U&E’s for creatinine and PSA
18
Q
What can a urinary dipstick test detect?
A
- Proteinuria
- Haematuria
- Glucose
- Ketones
- Bilirubin
- pH
- Nitrites and leucocytes - UTI
19
Q
Haematuria in different sections of the stream is indicative of different things. What are these?
A
Blood at start of micturition- urethral disease
Blood at end of micturition- bleeding from prostate or bladder base
Blood seen evenly throughout- bleeding from bladder or above
20
Q
Most common cause of glucosuria?
A
Diabetes mellitus
21
Q
Red cell casts in urine are pathognomonic for what?
A
Glomerulonephritis
22
Q
White cell casts in urine may be seen in what?
A
Acute pyelonephritis
23
Q
How are renal, bladder and prostate tumours staged?
A
CT
24
Q
How is polycystic kidney disease diagnosed?
A
Ultrasonography
25
Post void residual volume can be measured by...?
Ultrasonography
26
Define functional bladder capacity. What is the difference between this and anatomical bladder capacity?
Functional bladder capacity is the volume of urine released when patient attempts to empty their bladder.
There can be a post void residual volume, meaning that anatomical bladder capacity can often be much larger.
27
How is polyuria defined? (Calculation)
Urine output of >40ml/kg/24 hours (around 2.5-3L a day)
28
What causes PSA to be raised?
1. BPH
2. Prostatic cancer
3. UTI
4. Prostatitis
29
What screening tool is used in BPH, and can also be used to suggest management of the patient?
IPSS - International prostate symptom score
30
What is the general management of a patient with mild symptoms of BPH and an IPSS score of between 0 and 7?
Watchful waiting - until symptoms become worse
31
What is the general management of a patient with moderate or severe symptoms of BPH and an IPSS of 8-19?
1. Conservative treatment - fluid management, bladder drill, avoid caffeine
2. Drugs - alpha 1 blocker and/or 5-alpha reductase inhibitor
3. Surgery - often TURP - transurethral resection of prostate, open prostatectomy, green light laser, holmium enucleation of prostate
32
What is the gold standard surgery used in prostate resection?
TURP - transurethral resection of prostate
33
What is the most common side effect of TURP (transurethral resection of prostate)?
Retrograde ejaculation
34
Why are alpha-1-blockers prescribed in BPH? What effect do they have?
They are prescribed as contraction of the bladder neck and urethral sphincter is by the sympathetic nervous system (alpha-1 receptors cause this when NAd binds) meaning that if these receptors are blocked, the bladder neck will not contract so will relax to allow voiding.
35
Why are 5-alpha reductase inhibitors used in BPH and what effect do they have?
Cause prostatic cell apoptosis.
36
At what diameter can a bladder stone (calculi) still be destroyed by lasers, but if it got any bigger would have to be removed by surgery?
3cm
37
What are the main complications if LUTs are not treated?
1. Bladder calculi
2. UTI
3. Bladder decompensation
4. Incontinence
5. Haematuria
6. Acute retention
7. Decreased QoL
38
What is the difference between acute and chronic urinary retention?
Acute = pain, quick onset, >500ml in bladder
39
What are the two more serious causes of urinary retention to look out for?
1. Prostatic cancer
| 2. Spinal cord compression
40
Spinal cord compression is suspected cause of patient's urinary retention, what other symptoms are likely to be present?
1. Back pain
2. Radiating pain to legs
3. Diarrhoea
4. Loss os perianal sensation
5. Lack of sphincter control
6. Leg weakness
41
Give an example of a pre-renal cause of kidney failure
Hypovolaemia
42
Give an example of a renal cause of kidney failure
Kidney damage
43
Give examples of post renal causes of kidney failure
Obstruction of urine outflow - enlarged prostate, kidney stone, bladder tumour or injury
44
What stimulation causes the bladder neck and urethral sphincters to relax? ie. allow voiding
Decreased sympathetic stimulation (NAd). Must note main part of urethral control is under skeletal muscle control.
45
What stimulation causes the detrusor muscle to contract) i.e. allow voiding
Increased parasympathetic stimulation (ACh)
46
What type of tumour is prostate cancer and where does it arise?
Adenocarcinoma. Often multifocal. Arises in peripheral zone of prostate.
47
Where does prostate cancer most commonly metastasise to?
Lymph and bone. Occasionally to lung, liver and brain.
48
What are the common biomarkers for prostate cancer in both serum and urine?
Serum - PSA, PSMA
| Urine - PCA3
49
What is PSA?
Serine antigen responsible for liquefication of semen. Small amount found in blood.
50
If PSA level is over 20, what is the probability that the patient has prostate cancer?
90%
51
Outline the 5 steps in making a prostate cancer diagnosis
1. LUTS present
2. PSA high
3. Transrectal ultrasound scan (TRUSS)
4. Prostate biopsy
5. Confirmed and then graded (Gleason grading)
52
What grading system is used in prostate cancer?
Gleason
53
Explain gleason grading in prostate cancer
Gleason grading looks at the histological appearance of the most common and second most common cell morphology. A score from 1-5 is given to each, 1 being well differentiated and 5 being poorly differentiated. The scores are then added together.
54
What is the difference between grading and staging a cancer?
```
Grading = histological appearance and how they look under the microscope
Staging = how far the tumour has spread and how large it is
```
55
What is the difference between a well differentiated tumour and a poorly differentiated tumour and which has the best prognosis?
Well differentiated tumours have the best prognosis.
Well differentiated = cells of tumour and organisation of tumour are similar to that of normal tissue structure. This means they are likely to grow at a slower rate.
56
What are Partin's normograms?
Tables that use the clinical T stage, serum PSA and Gleason score to predice T and N staging.
57
How are stages T1, T2 and T3 defined in prostate cancer?
T1 No palpable tumour on DRE
T2 Palpable tumour, confined to prostate
T3 Palpable tumour extending beyond prostate
58
What investigations and tests would need to be done in order to stage a prostate cancer?
T - DRE
N - MRI/CT
M- Bone scan
59
Treatments for local prostatic cancer?
1. Radical prostatectomy - open, laparoscopic, robotic
2. Radiotherapy
3. Observation
4. Focal therapy - High intensity ultrasound
60
Commonest site of metastatic prostate cancer?
Bone
61
Why is there currently no screening programme in UK for prostate cancer?
- Test is neither particularly sensitive or specific - 15% of men that test negative may have cancer
- Test can find aggressive cancer as well as slow growing cancer that wouldn't have symptoms or shorten life span
- Risk of overtreatment - side effects of treatment can be serious (incontinence, sexual dysfunction)
- Increased anxiety
National screening committee = Risks outweigh benefits currently
62
What is the treatment for metastatic prostate cancer?
Androgen deprivation therapy (ADT)
- Bilateral orchidectomy
- GnRH analogue (both antagonist and agonist block secretion due to flare effect)
- LH antagonist
- Antiandrogens (peripheral receptor antagonists)
63
What is the median remission time for patients with metastatic prostate cancer on androgen deprivation therapy?
2.5 years
64
After remission phase of prostate cancer, what is the management?
Second line hormone therapy, cytotoxic chemo, bisphosphonates, and palliation (pain, spinal cord compression, ureteric obstruction and anaemia)
65
What urinary sphincters are present in a female and how is this different to a male?
Females have bladder neck but is often very weak, or absent in 1/4. They do however have a distal urethral sphincter that is the entire length of the urethra. It is enforced by the pelvic floor.
Males have both sphincters. The bladder neck prevents retrograde ejaculation.
66
What is the purpose of the bladder neck in a male?
Prevents retrograde ejaculation
67
What is the most common cause of stress incontinence in women?
Sphincter weakness due to birth trauma. Can also be congenital or neurogenic
68
What is the most common feature of stress incontinence?
Small leak of urine when intra-abdominal pressure increases (e.g. when coughing, laughing, standing)
69
What is the gold standard management of stress incontinence secondary to birth trauma? Other management?
Gold standard - pelvic floor exercises
Can also have surgery (sling, artificial sphincter) or duloxetine (SSNARI)
70
Why is the use of Duloxetine as a treatment for stress incontinence questioned?
Bad side effects - nausea
71
What is the most common cause of stress incontinence in male?
Iatrogenic (prostatectomy) or congenital
72
Define urge incontinence
Urgency with frequency, with or without nocturia in the absence of local pathology
73
How is detrusor overactivity diagnosed in a patient with an overactive bladder?
Cystometry
74
Outline the management for a patient with urge incontinence.
In mild cases can do behavioural therapy - less caffeine, alcohol, lose weight.
1. Antimuscarinics (anticholinergics) e.g. Tolterodone OR Mirabegron (B3 adrenergic antagonist) if anticholinergic contraindicated
2. Botox
3. Neuromodulation - percutaneous electrical stimulation into 3rd sacral nerve root - inhibits reflex bladder contraction. Permanent implant if over 50% improvement
4. Surgery (detrusor myectomy or cystoplasty)
75
In what patients is overflow incontinence often seen?
Men with BPH causing outflow obstruction. Will have a distended bladder on examination and will leak small amounts of urine.
76
What is the management of a patient with overflow incontinence?
Catheterise immediately or risk of renal failure
77
What part of the brain controls the coordination and completion of voiding?
Periaqueductal grey / pontine micturition centre
78
Where is the conus medullaris and what is it?
End of the spinal cord. Between L1 and L2
79
What is the significance of the conus medullaris in terms of neuro-urology?
If there is a lesion above it (L1-L2) the bladder will be a reflex bladder. If there is a lesion below it, the bladder will become flaccid.
80
A patient has an upper motor neurone lesion (above L1-L2). What is the effect on the bladder?
- Due to nature of lesion, S2-S4 will still be intact, meaning that spinal reflexes to the bladder will still occur
- However, coordination and completion of voiding is lost
- Reflex bladder contractions will occur resulting in involuntary urination
- Detrusor/sphincter dyssynergia
- Poorly sustained contraction.
81
A patient has a lower motor neurone lesion (below L1-L2). What is the effect on the bladder?
- Reflex bladder contractions and other spinal reflexes e.g. guarding reflex lost
- Detrusor areflexia (inability to void either completely or fully- fills until overflows)
- Poor compliance
82
There are many differences in how UMN lesions and LMN lesions affect a patient's urological functioning. What is the main similarity?
Neither allow the bladder to empty effectively
83
Give some causes of a flaccid bladder due to LMN lesion?
- Spina bifida
- Sacral fracture
- Transverse myelitis
- Ischaemic injury
- Cauda equina syndrome
84
What is autonomic dysreflexia?
Excessive hypertension that can occur with UMN lesions above T6
85
How does autonomic dysreflexia often present?
Excessive hypertension, headache, flushing
86
What causes autonomic dysreflexia?
Overstimulation of the sympathetic nervous system below spinal cord lesion in response to noxious stimuli (actual or potentially tissue damaging event)
87
How is autonomic dysreflexia treated?
- GTN spray (vasodilator)
| - Removal of cause
88
Define an 'unsafe bladder'
One that puts the kidneys at risk
89
What 3 factors in the bladder can put the kidneys at risk of damage? (Unsafe bladder)
1. Raised bladder pressure --> hydronephrosis --> renal failure
2. Vesico-uteric reflux
3. Chronic infection
90
What are the two potential ways of managing a reflex bladder?
1. Harness reflexes into incontinence device (note may not keep safe)
2. Suppress reflexes --> flaccid bladder and empty regularly (ISC/LTC)
91
What is the main risk with convene drainage in an incontinent patient?
Can develop incomplete bladder emptying- can be dangerous for kidneys
92
What is the main urological management of a tetraplegic patient?
1. Suprapubic indwelling catheter/ urostomy - as they cannot ISC due to loss of hand function
2. Convene drainage
93
What is the main urological management of a paraplegic patient?
Can intermittently self catheterise due to remaining hand function.
a) Suprapubic
b) Convene
c) Supress reflexes (using anticholinergics/mirabegron) --> flaccid bladder and then ISC
94
What is the main management of a patient with neurogenic stress incontinence? (male and female)
Male - Artificial sphincter
| Female - Autologous sling/ artificial sphincter
95
How is the bladder function affected in a patient with MS?
Get neurogenic detrusor overactivity causing urgency and frequency, incomplete bladder emptying --> uti's and incontinence.
96
What is the urological management of a patient with MS?
1. Anticholinergics
2. ISC
3. IDC
97
Name causes of discoloured urine (other than haematuria)
1. Myoglobinuria - due to rhabdomyolysis. Urine is dark in colour
2. Beeturia - red colour (due to betanin)
3. Haemoglobinuria - purple colour
4. Drugs - e.g. rifampicin = red colour
98
What is glomerulonephritis?
Inflammation within the glomeruli of the kidney
99
What 3 signs can glomerulonephritis cause?
1. Leaky glomeruli (proteinuria and haematuria)
2. High blood pressure
3. Decreasing kidney function (causes 25% of all end stage renal failure)
100
How does glomerulonephritis present (4 conditions)?
1. Acute nephritic syndrome
2. Nephrotic syndrome
3. Asymptomatic urinary abnormalities
4. CKD
101
Most protein (low molecular weight) is reabsorbed where in the nephron?
Proximal tubule
102
What is the underlying pathology of glomerulonephritis?
Immune mediated inflammation (immunoglobulin deposits, inflammatory cells and responds to treatment)
103
What is the difference between glomerulonephritis and glomerulopathies?
Glomerulonephritis is inflammation of the glomeruli, with in glomerulopathies, there is no evidence of inflammation. There is very large overlap.
104
What two hormones have opposite effect on the sodium and water retention of the kidney?
Aldosterone and ANP
Aldosterone promotes Na/K pumps, which means increased sodium and water reabsorption and increased potassium secretion in the distal tubule and collecting duct. Also upregulates ENaC's
ANP increases GFR (dilates afferent and constricts efferent) and decreases sodium and water reabsorption. Also inhibits renin secretion
105
What is the pathology of nephrotic syndrome?
Increased filtration of macromolecules across the glomerular capillary wall due to abnormalities of the glomerular podocytes
106
What clinical signs are seen classically in nephrotic syndrome?
1. Massive proteinuria
2. Hypoalbuminaemia
3. Oedema
4. Frothy urine
5. Hypercholesterolaemia
6. Hypercoaguable
107
Why is oedema seen in nephrotic syndrome?
Increase in capillary permeability as well as sodium retention in collecting tubules.
108
Why is hypercholesterolaemia and a hypercoaguable state seen in a patient with nephrotic syndrome?
Nephrotic syndrome leads to massive proteinuria and therefore hypoalbuminaemia. The liver attempts to compensate for this by going into overdrive meaning that there is increased production of clotting factors and of cholesterol.
109
What is the classic presentation of a patient with nephrotic syndrome?
Frothy urine, oedema of the ankles, genitals and abdominal wall.
110
The differential diagnoses of nephrotic syndrome are CCF and cirrhosis (see hypoalbuminaemia and oedema). How can you differentiate from these?
1. CCF- JVP is raised unlike in nephrotic syndrome
| 2. Cirrhosis - will see other signs of chronic liver disease
111
What specific diseases can cause nephrotic syndrome?
Minimal change disease, membranous disease, FSGS, amyloid
112
How do you diagnose any form of glomerulonephritis (nephrotic syndrome, acute nephritic syndrome etc)
Renal biopsy
113
Management of a patient with nephrotic syndrome?
1. Diuretic (and dietary salt restriction)
2. Statins (to lower cholesterol)
3. Warfarin (to anticoagulate)
4. ACE inhibitor - reduces angiotensin II mediated efferent arteriolar vasoconstriction
5. Prophylactic ab's in children - loss of immunoglobulin in urine
114
Why can ACE inhibitors be prescribed in nephrotic syndrome?
ACE inhibitors reduce affect of angiotensin II mediated efferent arteriolar vasoconstriction, meaning pressure in glomerulus drops and protein filtered also drops.
115
A typical case of a post-streptococcal glomerulonephritis develops in a child how long after infection?
1-3 weeks
116
What are some of the causes of acute nephritic syndrome?
ANCA associated vasculitis, goodpasteur's disease, post-streptococcal infection, SLE, systemic sclerosis
117
What are the main clinical features of a patient with acute nephritic syndrome?
1. Haematuria (visible or non visible) - red cell casts often seen on microscopy
2. Proteinuria
3. Hypertension and oedema
4. Oliguria
5. Uraemia
118
Patient presents with acute nephritic syndrome. Hypertension is a key clinical feature of these patients, what are some classical features of hypertension?
1. Retinal haemorrhages
2. LVH
3. Crepitations in lung
4. Increased JVP
119
Commonest cause of asymptomatic urine abnormalities?
IgA nephropathy
120
Patient presents with urolithiasis. They ask you what their risk of getting it again is?
50% lifetime recurrence
121
What is the commonest age to develop kidney stones?
30-50
122
Why does urolithiasis occur?
1. Anatomical - horseshoe kidney, duplex , PUJO, spina bifida, obstruction, trauma etc
2. Urinary factors - dehydration, calcium, urate, cysteine
3. Infection
123
What is the most common cause of urolithiasis?
Dehydration
124
What stone is most commonly found in urolithiasis?
Calcium oxalate (65%)
Note: 80% are calcium salts (oxalate or phosphate)
125
Why are uric acid stones in urolithiasis often hard to identify?
Are lucent on xray
126
How can urolithiasis be prevented?
1. Reduce salt and protein
2. Lose weight (reduce BMI)
3. Overhydrate
4. Drink citrus fruit juice
5. Active lifestyle
6. Include dairy in diet
127
How are uric acid stones removed?
Deacidify urine- they will dissolve
128
What is the advice given to patients with cysteine stones?
1. Alkalinise urine
2. Overhydrate massively - 3.5-4.5L a day
3. Genetic councilling
129
What form of urolithiasis is genetically linked?
Cysteine stones
130
What are the symptoms of a person with urolithiasis?
1. Loin pain/ renal colic
2. Haematuria (NV)
3. LUTS (freq/dysuria)
4. Recurrent infection
5. Can be asymptomatic
131
Describe the character of the pain often associated with urolithiasis?
1. Colic pain (due to peristaltic ureter)
2. Unilateral loin pain
3. Quick onset
4. Unable to get comfortable
5. Radidates to groin or tip of urethra
6. Assosciated with nausea/vomiting
7. Classic 12/10 pain
132
What are the differential diagnosis of urolithiasis?
1. AAA
2. Testicular torsion
3. Ectopic pregnancy
4. Bowel pathology (diverticulitis/appendicitis)
5. MSK
133
What is the gold standard imaging in urolithiasis. If the patient was a recurrent stone former how would this gold standard change?
Gold standard = NCCT-KUB
If recurrent stone former or pregnant would do ultrasound KUB instead, but is very poor at visualising ureter.
134
What investigations would you do in suspected urolithiasis?
- Urinalysis / MSU
- FBC, U&E, calcium, uric acid
- Imaging - NCCT-KUB
135
Why is it so important to do FBC and urinalysis in urolithiasis?
MUST identify INFECTION if there is any
| PYONEPHRITIS (infection and obstruction)
136
If patient has pyonephritis how would you manage them?
1. IV antibiotics
2. IVI oxygen (IV injection)
3. Escalate
4. Drain (nephrostomy/ ureteric stent)
137
What would cause you to treat a kidney stone?
1. Progression
2. Symptomatic
3. Pain
4. Infection
5. Obstruction
138
If a kidney stone is between 1-2cm and is symptomatic what is the most suitable method of treatment?
ESWL - Extracorporeal shock wave lithotripsy
139
If a kidney stone is symptomatic and larger than 2cm what is the most suitable method of treatment?
PCNL - Percutaneous nephrolithotomy
140
If a patient has multiple kidney stones and the function of the kidney is believed to be less than 10-15% what is the most suitable method of treatment?
Nephrectomy
141
If a patient has a ureteric stone, at what size would ESWL be used to remove it?
<4mm. If less than 4mm is likely to pass on own but any bigger must remove
142
What classification system is used for renal cysts?
Bosniak
143
What criteria would classify a UTI as complicated?
```
Urodynamic or structural abnormality
Pregnant
Male/child
Recurrent
Nosocomial
Patient immunocompromised
SIRS (systemic inflammatory response syndrome)
Renal disease
```
144
Pathogens most frequently responsible for UTI?
Ecoli or coagulase negative staph
145
What are the two types of pili that bacteria have and what type of infections do they lead to?
Type 1 pili = Lower UTI
| Type P pili = Upper UTI
146
What host factors mean that bacteria can adhere more successfully and cause UTI?
a) Oestrogen depletion (leads to loss of lactobacilli and increase in pH)
b) HLA blood group antigen non secretor (recurrent UTI)
147
In menopause what happens that means UTI's are more likely?
1. pH rises (loss of lactobacilli) - due to decreased oestrogen
2. Increased colonisation by colonic flora
3. Reduction in mucus secretion
4. Increased receptivity to UPEC (uropathogenic ecoli) on vaginal mucosa
148
How does the body naturally defend against UTI?
1. Antegrade flushing of urine
2. Tamm Horsfall protein - traps mannose sensitive bacteria
3. GAG layer
4. Low pH and high osmolarity of urine
5. Commensal flora
6. Urinary IgA
149
What is pyuria?
Presence of leucocytes in the urine, associated with infection
150
In what conditions is sterile pyuria most commonly seen?
STI / viral infection
151
Asymptomatic bacteriuria without pyuria (presence of leucocytes) is rarely a concern, apart from one exception?
In pregnancy - any bacteriuria should be treated
152
What are the common symptoms of cystitis?
Dysuria, frequency, urgency, suprapubic pain, haematuria, cloudy urine
153
What are the common symptoms of pyelonephritis?
High fever, rigors, vomiting, loin pain and tenderness
154
Common symptoms in prostatitis?
Flu-like symptoms, low back ache, few urinary symptoms, swollen or tender prostate
155
How is UTI diagnosed?
Generally is symptoms --> urinalysis
Nitrites and leucocytes is highly predictive of acute infection
--> gold standard = MSU MC&S
156
Main treatment for uti? and adjunctive advice?
Trimethoprim
Advice: increase fluid intake, void pre and post intercourse, avoid spermicides
157
What are the guidelines for what is classed as recurrent UTI?
>2 episodes in 6 months
| >3 episodes in 12 months
158
How would you investigate recurrent UTI?
1. MSU
2. Examination including DRE/PV
3. Post void bladder scan
4. USS of of renal tract and pelvis and XR/CT of KUB. Could also do flexible cytoscopy
Gold standard = contrast enhanced CT
159
What patients with UTI require renal imaging?
Complicated UTI, recurrent UTI and patients with fever/symptoms after 48-72 hours of treatment
160
What is the management of patients with recurrent UTI?
1. Advice - increase fluid intake, regular voiding, post intercourse, avoid spermicides or perfumed soaps
2. GAG replacement
3. Oestrogen replacement (vaginal)
4. Proanthocyadins (cranberry)
5. Low dose/postcoital AB prophylaxis
6. Self start AB therapy
7. Uro-vaxom (extract of ecoli to boost immune system against)
161
How does acute bacterial prostatitis present?
Systemically unwell, fevers, rigors, voiding LUTS, pelvic pain, boggy tender prostate
162
How does chronic bacterial prostatitis present?
Symptoms for greater than 3 months, recurrent UTI, pelvic pain, voiding LUTS, uropathogens in urine
163
How does chronic pelvic pain syndrome (chronic abacterial prostatitis) present?
Chronic pelvic pain. Can have LUTS, can have UTIs
164
What are the stages of NIDDK classification of prostatitis?
```
I = acute bacterial prostatitis
II = chronic bacterial prostatitis
III = chronic pelvic pain syndrome
IV = asymptomatic inflammatory prostatitis
```
165
What are the investigations and imaging that could be done in suspected prostatitis?
1. Urinalysis and MSU
2. Segmented urine/semen cultures
3. Bloods
4. STI screen
Imaging: TRUSS +- CT abdo/pelvis
166
Treatment of acute and chronic prostatitis?
Acute: Gentamycin and co-amoxiclav (IV). 2-4 weeks Quinolone once well
Chronic: Quinolone 4-6 weeks
167
What are the symptoms of urethritis?
Urethral pain, dysuria, discharge
168
What is the most common cause of urethritis? and management?
STI
| Best managed by GUM
169
What is the main differential diagnosis of epididymo-orchitis?
Testicular torsion
170
What are the most common causes of epididymo-orchitis? (age dependent)
<35 STI
| >35 UTI - elderly often catheter related
171
How would suspected epididymo-orchitis be investigated?
1st void urine -> CT/ NG PCR + urethral swab
MSU
Ultrasound to rule out abscess
172
What is the treatment for epididymo-orchitis for both STI and non STI related?
STI related --> Doxycycline + azithromycin
| Non STI related --> Quinolone
173
What is the classical triad of symptoms seen in pyelonephritis?
1. Loin pain
2. Fever
3. Pyuria
can also have sever headache, systemic upset and rigors
174
What 3 investigations/imaging techniques would be used in diagnosing pyelonephritis?
1. PV - rule out tubal/ovarian/appendix pathology
2. Bloods inc cultures
3. Ultrasound urgent - to rule out obstruction
175
Treatment for pyelonephritis?
```
IV gentamycin + co-amoxiclav
Drain obstructed kidney
Catheter if compromised
Analgesia
Oral abx when well
```
176
What is emphysematous pyelonephritis?
Gas forming organisms e.g. C.perfringens --> life threatening. Emergency nephrectomy must be done
177
What is the most common cause of pyelonephritis in children?
Reflux
Clinical sciences
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