1
Q
what are the stages of CKD
A
- kidney damage with normal or increased GFR >90
- 60-89
3a 45-59
3b 30-44 - 15-29
- <15 = kidney failure
2
Q
what are the three sites a kidney stone is likely to get stuck
A
- ureteric junction of renal pelvis - pelvourteric junction
- as the ureter passes over the iliac vessels
- where the ureter enters the bladder - vesouteric junction
3
Q
what is the surface anatomy of the kidneys
A
T11-L3
4
Q
what is the blood supply of the kidney
A
Renal artery branch of aorta at L1
5
Q
what is the path of the ureters
A
- run over psoas muscle
- cross iliac vessels at pelvic brim
- insert into trigone of bladder (smooth area - no rugae)
6
Q
what the nervous control of the bladder
A
- parasympathetic - pelvic nerve
- S2 - S4 (keep the urine off the floor)
- Ach neurotransmitter
- involuntary control
- detrusor muscle stimulated during voiding - sympathetic - hypogastric plexus
- T11 - L2
- noradrenaline
- involuntary
- internal urethral sphincter stimulated during storage - somatic nerve - pedunal nerve
- s2 -s4
- onuf’s nucleus - guarding reflex tells inappropriate to void
- Ach
- external urethral sphincter stimulated during storage
- can control this (context decides) - afferent pelvic nerve
- sensory nerve
- signals from detrusor muscle on how bladder full
7
Q
which part of the brain controls micturition
A
pontine micturition centre
8
Q
explain the physiology of micturition
A
storage phase
-as volume increases pressure remains low due to receptive relaxation due to muscle compliance of detrusor muscle
filling phase
- afferent pelvic nerve sends slow firing signals to pons
- SNS stimulation/PSNS inhibition maintains detrusor relaxation
- somatic stimulation (pudendal) maintains urethral contraction
voiding phase
- micturition reflex autonomic spinal reflex
- sacral micturition centre receives fast signals via afferent pelvic nerve
- PSNS stimulated so detrusor contracts
- SNS inhibited so IUS relaxes
- somatic inhibited so EUS relaxes
9
Q
what are the symptoms or storage and voiding disorders
A
storage - frequency -nocturia -urgency - incontinence voiding - hesitancy - straining - poor/intermittent stream post micturition dribbling - incomplete emptying - haematuria -dysuria - painful
10
Q
what is the difference between BPH and BPE
A
BPH - benign prostatic hyperplasia - is a histological diagnosis based on increased number of cells in the prostrate
- increase in epithelial and stroll cell numbers in periurethral area of prostrate due to increased production or decreased apoptosis (transitional area)
BPE - is a clinically diagnosis based on increased physical size of prostrate found on a PR exam
11
Q
what are the symptoms of BPH
A
LUTS (lower urinary tract symptoms)
- nocturnia
- urgency
- frequency
- post micturition dribbling
- poor stream/flow - hesitancy
- haematuria
12
Q
what are the tests for BPH
A
- U+E
- US
- PR exam
- MSU
- biopsy
13
Q
what is the management of BPH
A
lifestyle
- avoid caffeine and alcohol to reduce the frequency
- drink less in evening - to decrease nocturnia
- double voiding - fully emptied bladder
- bladder training - aim to try and increase time between urination
drugs
- alpha blocker - decrease smooth muscle tone in prostrate and bladder making it easier to pass urine e.g tamsulosin
- anticholinergics to relax an overactive bladder
- 5 alpha reductase inhibitors e.g finasteride decrease prostrate size - inhibits testosterone —> dihydrotestosterone
- desmopressins slow down urine production for at night
surgery
- Transurethral resection of prostrate (TURP) - removal of part of prostrate with a tube that passes through urethra
- cytoplasty - increase size of bladder by adding piece of intestine - helps men whose bladder contracts before its full
- open prostectomy - removal of prostrate if very large
- urinary diversion - stoma for urine outside of body
14
Q
what are the complications of BPH
A
- symptom progression
- infections
- stones
- haematuria
- acute retention
- chronic retention
- interactive obstructive uropathy
15
Q
what are the features of acute retention of urine
A
- painful
- relieved by catheterisation
- 600-1L residual urine]
- normal U+E’s
16
Q
what is interactive obstructive uropathy
A
- functional or anatomic obstruction of urine flow at any level of the urine tract
- residual up to 4L
- causes nocturnal enuresis (bed wetting)
- can cause kidney failure during diuresis when catheterised
- do lying and standing BP to assess likelihood of this
17
Q
What are the indications for surgery with LUTS
A
mnemonic
Retention UTI's Stones Haematuria Elevated creatinine due to bladder outflow obstruction Symptom deterioration
18
Q
what is hydronephrosis
A
- dilation of the renal pelvis of calyces causing urinary tract obstruction
19
Q
what is the difference between supra vesicle and infra vesicle urinary tract obstruction
A
supravesicle - above level of bladder - drain with stent or nephrostomy
infravesicle - below the level of bladder e.g BPE
20
Q
what are the causes of urinary tract obstruction in the renal tract, ureter and bladder/urethral
A
renal
- congenital e.g polycystic kidney disease
- neoplastic
- inflammatory e.g TB
- metabolic - calculi/stones
ureter
- congenital - stricture
- neoplastic - pressing on ureter
- inflammatory - TB
Bladder/urethral
- congenital - urethral valve
- neoplastic
- inflammation
21
Q
what is the definiton of UTI
A
a pure growth of more than 10^5 organisms per ml collected from a fresh clean catch sample
22
Q
why might patients get renal stones
A
anatomical - congenital (horseshoe, duplex, spina difada, PUJO - pelvouretic junction obstruction) - aquired (obstuction, trauma, reflux) urinary - dehydration - calcium, oxalate, urate, cysteine - metastable urine infection
23
Q
what are the four types of renal stones/what are they made of
A
- Calcium - oxalate, phosphate
- uric acid - lucent on KUB XR
- struvite - infection stones
- cysteine - congenital (COLA)
24
Q
What are the prevention methods for urinary stones
A
- overhydration - 2.5/3L per day urine output
- low salt/sodium diet - can increase calcium in urine
- normal dairy intake
- healthy protein intake (inc uric acid levels)
- reduce BMI
- active lifestyle
- for uric acid stones - alkanization of urine as uric acid stones only form in acidic urine - use sodium bicarbonate or potassium citrate
- for cysteine stones - excessive overhydration, alkanization and cysteine binders - e.g penicillamine
- calcium stones - in hypercalcuria use thiazide to decrease calcium excretion
25
what are the symptoms of urinary stones
- pain loin to groin with nausea and vomiting 'renal colic'
- UTI symptoms - dysuria, strangulation, urgency, frequency
- haematuria
- proteinuria
-sterile pyuria (pus)
-anuria
-
26
what are the tests for urinary stones
- FBC, U+E, Ca2+, phosphate, glucose, bicarb, urate
- dipstick positive for haematuria
- if urinalysis positive, MSU
- PH of urine
- calcium, oxalate, urate, citrate, sodium
- imaging - non contrast Ct for imaging stones, KUB XR
- NCCT KUB - non contrast computerised tomography - 99% sensitive for stones 90%specific
27
what are the differential diagnosis of urinary stones
- vascular accident e.g ruptured AAA >50years
- bowel pathology - diverticulitis, appendicitis
- gynae - ectopic pregnancy, ovarian torsion
- testicular torsion
- MSK pain
28
what is the management of urinary stones
analgesia
- NSAID suppository
- opiates
antiemetics
IV fluids
medical expulsive therapy if do not pass naturally
- nifedipine (CCB)
- alpha blockers (tamsulosin)
urgent intervention if infection or obstruction
-percutaneous nephrostomy or ureteric stent -Extracorporeal shock wave lithotripsy (ESWL)
29
what is the pathology and epidemiology of prostrate cancer
- mean diagnosis 72
- family history 5-10%
- 12-16% LIFETIME RISK
- adenocarcinoma of the peripheral zone of prostrate
- 85% multifocal
- spreads locally through prostrate capsule
- metastasis to lymph nodes and bone (sclerotic)
- androgen sensitive - fusing of gene and onco gene - upregulation of oncogene when androgen fuses
30
what are the tests for prostrate cancer
- serum PSA (prostrate specific antigen)
- tissue
- urine - PCA3 and gene fusion products
- CT/MRI, US, biopsy, bone scan
31
what is PSA and the problems with prostrate cancer diagnosis because of it
- prostrate specific antigen
- not cancer specific
- can be elevated due to other causes - but most commonly cancer
- e,g BPE, UTI, prostatitis
- 70% of men with a raised PSA will not have prostrate cancer
- 6% of men with a normal PSA will have prostrate cancer
- with PSA there is an earlier age of presentation (lead time bias) and more confined prostate cancer diagnosed
- can cause over diagnosis and over treatment - often prostrate wouldn't be diagnosed
32
which grading is used for prostrate cancer
gleason grading
| - histological diagnosis due to appearance of tissue (1-5, 5 being poor)
33
what is the staging of prostrate cancer
T1 - not palpable
T2 - palpable confined to prostrate
T3 - extends beyond prostrate
34
what are the symptoms of prostrate cancer
- nocturia
- hesitancy
- poor stream
- terminal dribbling
- obstruction
- weight loss bone pain = metastases
35
what is the treatment of prostrate cancer
localised disease
- surgery - radical prostectomy - open, laproscopic, robotic
- radiotherapy - external beam or bracytherapy (placed in/near area)
-observation - active monitoring
- hormone therapy
advanced
locally
- radiotherapy
- radical prostectomy
metastasic
- surgical castration - remission of advanced disease
- androgen deprivation therapy - LHRH antagonists blocks release of testosterone
36
what are the benefits and risk of prostrate cancer screening
```
benefits
- early diagnosis of localised disease
- early treatment of advanced disease
risk
- increased anxiety
- costs
-harm caused by investigation/treatment
- over diagnosis of insignificant disease
```
37
what are the differential diagnosis of haematuria
- infection - UTI, pyelonephritis, TB
- malignancy - anywhere in tract
- trauma - penetrating vs blunt
- stones - bladder, kidney, ureteric
- nephrological - diabetes, nephropathy
38
what are the criteria for a 2 week wait for bladder cancer
- aged 45 and over and have - unexplained visible haematuria without UTI or visible haematuria persisting after successful UTI treatment
- aged 60 and over with unexplained non visible haematuria and either dysuria or increased WCC
39
what are the investigations for bladder/renal/testes cancer
- FBC, U+E, PSA, glucose
- MSU/dip: microscopy, culture, sensitivity
- cytology - direct look at cells
- USS, CTU
- cystoscopy - tube up bladder with biospy
40
what is the presentation of bladder cancer
- painless VH
- recurrent UTI's
- irritative voiding
41
what are the risk factors for bladder cancer
- smoking - urinary excretion of inhaled carcinogens
- aromatic amines
- chronic cystitis
- pelvic irradiation
- paraplegia -catheters - irritation causing squamous tumour
- drugs
- stones - squamous
42
what is the pathology of bladder cancer
- 90% transitional cell carcinoma (TCC)
- 5% squamous - related to inflammation e.g parasitic infection (SCC)
- 1% adenocarcinoma
43
what is the grading of bladder cancer
1- differentiated (original cell) only through lamina propria not muscle
2. intermediate
3 - poorly differentiated
44
what is the treatment of bladder cancer
```
grade 1
- transurethral resection of bladder tumour (turbt) scope removal of tumour
- BCG intravesicle treatment through catheter - stmulates non specific immune response
grade 2+3
- radial cystectomy - bladder removal
-chemo
4
- palliative chemo/radio
```
45
what are the main types of renal cancer
- 95% RCC
| - 5% TCC - transitional cell carcinoma
46
what is the presentation of renal cancer
- haematuria
- loin pain
- adbo mass
- weight loss
- malaise
- anorexia
47
what is the staging of renal cancer
1 - <7cm limited to kidney - remove kidney or partial neprectomy
2- >7cm (limited to kidney)
3- tumour in major veins or adrenal gland - radical nephrectomy + adrenalectomy
4- tumour beyond Gerotus fascia, distant metastases - nephrectomy (cytoreductive), systemic treatment
48
what is the distuingishing feature of a true testicular mass
you are able to get above it when examining
49
what should you think of when a patient has acutely painful testis
testicular torsion until proven otherwise
50
what is epididymitis
- swollen epididymis due to spread of ecoli or chlamydia from prostatic urethra and seminal vesicles
51
what is a hydrocele
excessive fluid in tunica vaginalis
| - primary in young boys, secondary = pathology - tumours, infections
52
what is the testicular appendix
remnant of the Mullerian duct
53
what is a varicocele
dilated veins of the pampiniform plexus
54
what are the risk factors for developing a testicular tumour
- cryptochidism (undescended testes)
- infant hernia
- infertility
55
what is the presentation of a testicular tumour
```
- painless lump in testes
can be felt above
- hard
-does transilluminate
- hydrocele
- pain unexplained
- metastases e.g lung, abdo, cervical nodes
```
56
what are the tests for a testicular tumour
- USS
- B-HCG marker, AFp
- CXR -resp symptoms
- CT - staging
57
what is the management of testicular tumour
- radical orchidectomy - testes and spermatic cord
- seminomas very radiosensitive (slow growing)
- teratomas - cytotoxic chemo
- treatment causes sterility - collect sperm
58
what are the layers of the glomerulus filtration barrier
capillary - endothelium - BM - podocyte foot processes - bowmans space
59
what determines if a molecule can cross the filtration barrier
1. size of molecule
2. charge of molecule - BM is negative
3. binding to plasma proteins
4. rate of blood flow
5. pressure gradient
60
how much blood does each kidney recieve per min
1 litre of 5litres cardiac output
61
how is eGFR predicted
from age, gender, race (creatinine generation)
- require steady state
- may be misleading in high muscle mass
- creatinine also secreted by the kidney
- inhibitors of this will cause increased serum creatinine and make function look worse e.g trimethoprim
62
what is fanconi syndrome and what are the symptoms
- proximal tubular insult
- glycosuria
- acidosis
- phosphate wasting - rickets/osteomalacia
- aminoacid uria
- caused by wilsons, cystinosis, glycogen storage disease
63
what is the action of aldosterone on the kidney
increases transcription of ENac channels in the collecting duct
causes influx of Na and efflux of K
64
what is the action of ADH on the kidney
ADH acts on principal cells by acting on V2R receptor, causing aquaporin 2 insertion into the apical membrane
increased water permeability
also a direct vasoconstrictor
65
where is aldosterone released from
zona glomerulosa of adrenal cortex
66
what does renal artery stenosis cause
- increased systemic BP due to decreased delivery of Na to macula densa, even though body Na levels are normal
- can be treated by stenting
- flash pulmonary oedema
67
how do NSAIDS damage the kidney
- prostaglandins cause afferent vasodilation
- NSAIDS block PG production
- causes afferent vasoconstriction
- decreased GFR
68
which molecule is responsible for constriction of the efferent arteriole
angiotensin II
| - this is why ACE I and ARB are contraindicated in acute kidney insults and renovascular disease
69
what drives cellular K+ uptake in the short and long term
short term
-insulin and catecholamines
long term
- aldosterone and Na
70
what does increased vit D cause
- increased calcidiol formation in liver
- increased calcitriol formation in kidneys
- which causes decreased calcium excretion at kidneys, increased calcium release from bone, and increased calcium absorption in the small intestine
- leading to increased serum calcium
71
which channel transports calcium in the small intestine
plasma membrane calcium pump ATPase
72
what is renal anaemia
- deficiency of EPO in advanced kidney disease leads to decreased haemopoesis and anaemia
- exacerbated by functional iron deficiency in renal disease
- seldom seen until eGFR below 30
73
what is the definition of acute kidney injury
- rise in creatinine >26micromol/L in 48 hours (above baseline)
- rise in creatinine > 50% (best figure in last 6 months)
- urine output <0.5ml/kg/hr for >6 consecutive hours
1 out of 3 needed
74
what are the pre renal causes of AKI
- decreased vascular volume - haemorrhage, D+V, pancreatitis
- decreased CO - cardiogenic shock, MI
- systemic vasodilation - sepsis, drugs
- renal vasoconstriction - NSAIDS, ACEI, ARB
75
what are the renal causes of AKI
- glomerular - glomerulonephritis, ATN
- interstitial - drug reaction, infection, infiltration
- vascular - vasculitis, DIC, TT, HUS
76
what are the post renal causes of AKI
- extrinsic compression - pelvic malignancy, prostratic hypertrophy, retroperitoneal fibrosis
- within renal tract - stone, renal tract malignancy, stricture, clot
77
give two life threatening complications of AKI
- pulmonary oedema - furosemide
| - hyperkalaemia - treat if >6.5mmol/L or ECG changes (insulin and dextrose, calcium gluconate, IV fluid, salbutamol)
78
what are the investigations of AKI
- dipstick and quantification of proteinuria (haematuria/proteinuria may suggest intrinsic disease)
- USS within 24 hours - small kidneys suggest CKD, asymmetry suggests renal vascular disease
- liver function - hepatorenal disease
- platelets (HUS/TTP)
79
what is the management of AKI
- monitor - fluids/balance, K+, vitals, lactate if sepsis
- treat hypovolaemia
- treat sepsis
- stop nephrotoxic medication - NSAIDS, ACEI, ARB
- stop drugs that may increase complications e.g diuretics
- check drug doses
- dialysis
80
what are the indications for dialysis in AKI
- pulmonary oedema
- persistant hyperkalaemia
- metabolic acidosis
- uraemia encephalopathy or pericarditis
- drug overdose
81
what are the types of RRT + describe
haemodialysis
- blood is passed over a semi permeable membrane against dialysis fluid flowing in the opposite direction
- diffusion of solutes occurs down the concentration gradient
- a hydrostatic gradient is used to clear excess fluid as required
- access via arteriovenous fistula
-HD needed 3 times a week or more - time consuming
Peritoneal dialysis
- uses the peritoneum as a semi permeable membrane
- a catheter is inserted into the peritoneal cavity and fluid infused
- fluid diffuses slowly across
- continuous and performed at home
- can get infection of catheter
- loss of membrane function over time
82
what is chronic kidney disease
- abnormal kidney structure or function, present for >3 months with implications for health
- GFR < 60ml/min/1.73^2 on at least 2 occasions 90 days apart
- markers of kidney damage
83
what are the stages of CKD by GFR
```
G1 >90 - if other evidence of kidney damage: protein/haematuria
G2 60-89
G3a 45-59
G3b 30-44
G4 15-29
G5 <15
```
84
what are the stages of CKD by albuminuria
stage albumin ACR (albumin:creatinine)
A1 <30mg <3
A2 30-300 3-30
A3 >300 >30
85
What are the causes of CKD
- diabetes - inc glucose can decrease NO (vasodilator) causing increase renal bp
- glomerulonephritis
- Inc BP/renovascular disease
- high cholesterol
- infections
- polycystic kidney disease
- long term use of NSAIDS
- blockage in urine flow e.g recurrent stones
86
what are the tests for CKD
- eGFR
- dipstick: ACR and other proteins
- U+E, Hb, Ca2+ decrease, phosphate increase, PTH increase, ANA, ANCA (for intrinsic renal disease)
- USS for site, symmetry, exclude obstruction
- biopsy
87
how should CKD be monitored
- GFR and ACR at least annually
- if high risk - every 6 months - high risk:
- G3b+
- A2 + G3a
- A3
- if very high every 3-4 months
- small fluctuations are common but a decrease of 25% is significant
88
what is the management of CKD
- appropriate referral to nephrology
- treatment to slow renal disease progression
- treatment for renal and other complications of CKD
- preparation for renal replacement therapy
89
when should you refer a renal CKD patient to nephrology
- stage G4 +G5
- ACR > 70mg or 30mg with haematuria
- declining GFR of >25%
- BP poorly controlled despite >4 antihypertensives at therapeutic dose
- known or suspected rare or genetic causes of CKD
90
what is the treatment use to slow renal progression in CKD
- ARB or ACE - don't combine due to risk of hyperkalaemia
- glycemic control
- lifestyle - exercise, healthy weight, smoking cessation, decreased salt intake
- BP targets 140/90 or if ACR >70 130/80
91
what is the treatment of renal + other complications in CKD
- anaemia
- acidosis - sodium bicarbonate
- oedema - restrict Na + fluid intake, loop diuretic/thiazide
- CKD bone mineral disorders
other
- inc CV disease risk - anti platelets, atorvostatin
92
describe preparation for RRT
- should begin in progressive CKD when risk of kidney failure is 10-20% within a year
- listed for a deceased donor transplant 6 months before RRT scheduled
- efforts made to find a preemptive living donor
93
what are the contraindications for renal transplant
- absolute: cancer with metastases
- temporary: active infection, HIV, unstable CVD
- relative: congestive heart failure, CVD
94
describe the different types of kidney donation
- living donor: best graft function and survival, especially if HLA matched
- deceased donor - 1 donor after brain death, 2. expanded criteria donor (older kidney) 3. donor after cardiac death
95
wha are the different means of immunosuppression
- glucocorticosteroids - decrease transcription of inflammatory cytokines, SE: BP, hyperlipidaemia, osteoporosis, diabetes mellitus, impaired wound healing, skin fragility, cataracts
- monoclonal antibodies e.g daclizumab (selectively block activated T cells via CD25)
- antimetabolites
- calcineurin - inhibit T cell activation and proliferation
96
what is the management of a patient who has had a renal transplant
- infection risk especially opportunistic
- increased malignancy risk
- rejection - acute (antibody mediated or cellular) or chronic (causes increased loss of function of the graft)
- no vaccinations with live organisms
- good personal hygiene must be upheld
- avoid foods with high risk of food poisoning
97
what is glomerulonephritis
- a number of conditions which are caused by pathology in the glomerulus
- present with haematuria, proteinuria or both
- are diagnosed on renal biopsy
- cause CKD
- can progress to kidney failure
- exist on a spectrum from nephrotic (proteinuria due to podocyte pathology) to nephritic (haematuria due to inflammatory damage)
98
what are the investigations for glomerulonephritis
- dipstick: protein, ACR
- blood: FBC, U+E, LFT, CRP, Ig, electrophoresis, autoantibodies
- CXR (pulmonary haemorrhage), RUS
- renal biopsy - for diagnosis
99
what is the management of glomerulonephritis
- general as for CKD including BP control and inhibition of renin angiotensin axis
- steroids
- statin
- antithrombotics
- other treatment depends on diagnosis
100
what are the features of a nephritic glomerulonephritis
- haematuria
- cola coloured urine
- inflammation of the glomeruli
- red cell casts on blood film
101
describe IgA nephropathy
- commonest GN
- diffuse mesangial IgA deposits
- asymptomatic NHV or episodic VH
- slow disease, progressing to renal failure over 30 years
- ACEI/ARB reduce proteinuria and protect against further renal decline
- corticosteroids and fish oil if persistent proteinuria
- lower cholesterol
102
list some nephritic GN
- small cell vasculitis
- IgA nephropathy
- lupus nephritis
- post streptococcal GN
- antiglomerular basement membrane anti GBM (autoantibodies to type IV collagen)
103
what is lupus nephritis
- when SLE effects kidneys
- ISPN classification from 1-6 with 6 being the worst
- immunosuppression and supportive care
104
what is post streptococcal GN
- after throat infection
- streptococcal antigen resides in glomerulus
- immune complex formation and inflammation
105
describe nephrotic GN
- proteinuria >3g/24hours
- hypoalbuminaemia
- oedema
- hyper coagulability
- hyperlipidaemia
- podocyte pathology
106
give two nephrotic GN
- membranous nephropathy
| - minimal change disease
107
describe membranous nephropathy
- thickening of glomerular capillary wall
- IgG, complement deposit in sub epithelial surface causing leaky glomeruli
- primary or secondary to malignancy, autoimmune disease e.g RA, SLE, infection e.g hepB/C, drugs
primary: glomerular podocyte membrane PLA2R is target in 70-80% (autoantibody)
- treat with ACEI/ARB + BP control
- control of oedema, hypertension, hyperlipidaemia and proteinuria
108
what is urge incontinence/overactive bladder
- urgency with frequency, with or without nocturia, appearing in the absence of local pathology
109
what is the management of overactive bladder
- behavioural therapy - bladder training, frequency volume chart, decreased caffeine and alcohol
- antimuscarinic agents - decreased PSNS activity by blocking M2/3, SE - dry mouth
- B3 agonists - increase SNS in bladder
- Botox - blocks neuromuscular junction for Ach release SE - incomplete bladder emptying and need to catheterise in 15%
- sacral neuromodulation - insertion of electrode to S3 nerve root to modulate afferent signals from bladder
- surgery - augmentation cytoplasty
110
what is stress incontinence
due to weakening of the pelvic floor
often secondary to birth trauma - due to denervation of the pelvic and urethral and weakening of fascial support of bladder and urethra
- congenital
- neurogenic
111
what is the management of stress incontinence
pelvic floor physio
surgery - sling, bulking agents, duloxetine
112
what are the parameters of bladder diaries
```
frequency day/night
volume day/night
nocturnal volume
functional capacity
incontience/day
```
113
what is the physiology of an erection
- release of NO
- Ca2+ and cGMP hyper polarises this
- relaxes sm cells
- allows engorgement
114
which enzyme returns a penis to the flaccid state
phosphodiesterase
115
which nerves cause erection and return to flaccid
erection - S2-S4 PSNS
flaccid - T11-L2 sympathetic
(both carried in cavernous nerve)
116
what is the anatomy of the penis
- 2 corpus cavernosa covered by tunica albuginea
- contains spongy vascular erectile tissue
- corpus spongiosum contains urethra
- supplied by pudendal artery of internal iliac
117
what is erectile dysfunction
the persistent inability to attain and sustain an erection sufficient to permit satisfactory sexual performance
118
what are the causes of ED
- smoking
- alcohol
- diabetes
- endocrine - hypogonadism hyperthyroidism
- neuro cord lesions, MS
- pelvic surgery - prostate
- psychological - indicators - sudden onset, good nocturnal and early morning erections, situational ED, younger patient
119
what are the tests for ED
- sexual history
- testosterone
- examine genitalia
- prostrate
- hypogonadism - small testes
- lipids
- glucose
120
what is the treatment of ED
- of underlying condition
- decrease risk factors
- weight loss
- exercise
- 1st line- phosphodiesterase inhibitors e.g sildenafil/viagra (requires sexual stimulation)
- 2nd line- vacuum devices and other drugs such as intracavernosal injection
- 3rd line -penile prosthesis implant
121
what are the classifications of UTI
complicated
- structural/functional abnormality of GU tract
- pregnant
- men
- catheter
- recurrent
- immunocompromised
- urosepsis
uncomplicated
- normal renal tract structure and function
asymptomatic bacteriuria
122
what are the risk factors for UTI
- increased bacterial occupation: sexual activity, urinary incontinence, faecal incontinence, constipation
- increased binding of uropathogenic bacteria: spermicide use, decreased oestrogen, menopause
- decreased urine flow: dehydration, obstructed urinary tract
- increased bacteria growth: DM, immunosuppression, obstruction, stones, catheter, pregnancy
123
what are the symptoms of cystitis
- dysuria
- frequency
- urgency
- suprapubic pain
- haematuria
- polyuria
124
what are the symptoms of pyelonephritis
```
diagnostic
-loin tenderness
-fever
-pyuria
others
- rigor
-costovertebral pain
-septic shock
-cystitis symptoms
```
125
what are the symptoms of prostatitis
- pain - perineum, rectum, scrotum, penis, bladder, lower back
- fever
- malaise
- nausea
- urinary symptoms
- swollen or tender prostate on PR
126
What are the tests for UTI
- dipstick in non pregnant women - shows pyuria (leukocytes in urine), blood and positive for nitrites
- MSU culture
- blood tests: FBC, U+E, CRP, culture
- imaging: USS and referral to urology in men with upper UTI, failure to respond to treatment, recurrent UTI, pyelonephritis, unusual organism, persistant haematuria
127
what are the main organisms causing UTI
- e.coli >50%
- pseudomonas aeruginosa - recurrent UTI/underlying pathology
- staphylococcus saprophyticus (commensal of skin) in young women
- proteus - renal stone associated
- klebsiella - hospital/catheterised
128
what is the management of UTI
uncomplicated
- empirical treatment with 3 day course of trimethoprim or nitrofurantoin if eGFR >30 or if pregnant
- if fails culture urine and treat according to antibiotic sensitivity
```
complicated
- get expert health
- preterm birth in pregnancy and intrauterine growth restriction
-nitrofurantoin
men
- lower - nitrofurantoin
- prostatitis - fluoroquinolone
```
129
what are the symptoms of chlamydia trachomatous
```
often asymptomatic or:
- dysuria
-vaginal discharge
- intermenstrual bleeding
male
-dysuria
-urethral discharge
```
130
what is the treatment of chlamydia
- azithromycin or doxycycline
| - erythromycin in pregnancy
131
what are the symptoms of a Neisseria Gonorrhoea infection
urethral/vaginal discharge
| dysuria
132
what is the treatment with gonorrhoea
ceftriaxone and azithromycin
133
list some causes of urethritis
- gonorrhoea
- chlamydia
- non gonococcal urethritis (NGU)
- bacterial vaginosis
- genital candidiasis
134
what are the symptoms of genital candida and treatment
- dyspareunia - difficult or painful sex
- genital itch
- cottage cheese like discharge
- treat with azoles
135
what are the symptoms and treatment of bacterial vaginosis
-fishy
-thin
-white
discharge
-oral or PV metronidazole
136
what are the symptoms and treatment of NGU
- urethral discharge
- dysuria
- urethral discomfort
- treat with doxycycline
137
describe autosomal dominant polycystic kidney disease
- 1 in 400-1000
- 85% have mutations in PKD1 (chromosome 16)
-reach end stage kidney failure by 50's
- or PKD2 (chromosome 4)
- slower to reach ESRF by 70's
may be clinically silent or: loin pain, visible haematuria, cyst infection, hypertension, renal caliculi, liver cysts
- USS test of choice
- treatment
- water intake 3-4L per day may suppress cyst growth
- BP management
- treat infection
-plan for RRT
138
describe autosomal recessive polycystic kidney disease
- chromosome 6
- presents antenatally with renal cysts, congenital hepatic fibrosis ---> portal hypertension
- no specific therapy
139
what is the pathogenesis of UTI
```
colonic flora
colonisation of vagina
colonisation of urethral meatus
ascent of bacteria - bacteriuria
UTI
```
140
What are the host factors that cause UTI
- ureteric reflex
- female shorter urethra
- stasis of urine due to BPH, stones, stasis in pregnancy, low urinary volume
- catheter
- loss of oestrogenisation - post menopause PH in the vagina rises and the vagina becomes more colonised by colonic flora, decreased vaginal mucus and increased mucosal receptivity to UPEC
141
what is the most likely pathogen to cause a UTI
```
Uropathogenic E.coli (UPEC)
- virulence
pili and fimbrae for adherence
deployment of toxins - tissue damage
antimicrobial resistance
```
142
what would be found on a dipstick test for UTI
- haematuria
- proteinuria
- altered PH
- glucose - diabetics more prone to UTI
- leukocytes and nitrites specific for UTI
143
what would be found on microscopy for UTI
- white blood cells >10^4wbc/ml (pyuria)
- casts - renal pathology e.g glomerulonephritis
- bacteria - counts > 10^4 indicative of infection
- epithelial cells - poorly taken specimen
144
how is a UTI identified by culture
it is achromogenic - colour of culture decides what organism it is
145
describe catheter associated UTI
- insertion may carry bacteria
- at risk up to 24 hours post removal
- form biofilms (prosthetic material)
- hospitable environment
- incomplete voiding
146
when should asymptomatic bacteriauria be treat
in pregnancy
| not in elderly
147
what are the three types of prostatitis
1. acute bacteria
- systemically unwell, fever, rigors, significant voiding LUTS, pelvic pain, tender prostrate
2. chronic bacterial
- symptoms >3 months, recurrent UTI, pelvic pain, voiding LUTS, uropathogens in urine with or without blood
3. CPPS (chronic pelvic pain syndrome)
- chronic pelvic pain +/- LUTS+/- UTI
148
what is the pathology of prostatitis
- ascending infection from urinary tract
- haematogenous spread
- gram -ve organisms
149
what is the treatment of prostatitis
quinolone for 28 days
pain relief
stool softener
alpha blocker
150
what are the causes of epididymorchitis (sexual and non sexual)
```
sexually transmitted
- chylamidia
-gonorrhoea
- gram -ve
non sexually transmitted
- mumps
-TB
-candida
```
151
what are the symptoms and signs of epididymorchitis
- acute onset unilateral scrotal pain +/- swelling, urethritis +UTI symptoms
signs
- tenderness
- oedema (scrotal)
- erythema
- pyrexia
- urethral discharge
- hydrocele
152
what features suggest scrotal pain may be due to testicular torsion
- short pain duration
- nausea and abdo pain
- previous short duration orchalgia
153
what are the tests for epididymorchitis
- urethral smear
- dipstick
- swab
- FPU
- MSU:MC&S
- CRP+ESR
154
What is the treatment of epididymorchitis
- analgesia
- antibiotics - doxycline (STI) ofoxacicin/quinolone (non STI)
- sexual abstinence
- supportive underwear
- contact tracing
155
what are the complications of STI
- PID
- tubal factor infertility
- ectopic pregnancy
- chronic pelvic pain
- neonatal transmutation
- Fitz Hugh curtis syndrome
156
how is chlamydia diagnosed
```
- nucleic acid amplification tests
female
-self collected vaginal swab
-endocervical swab
-first void urine
male
-first void urine
```
157
how is gonorrhoea diagnoses
- near patient test
microscope of gram stained smear of genital secretions looking for gram -ve diplococci within cytoplasms of polymorphs
- culture
-NAAT
158
which organism causes syphilis
- treponema pallidum
159
what are the stages of a syphilis infection
- primary chancre - 95% genital skin, incubation 9-90days, macule - papule- ulcer
- secondary (primary may be present concurrently) - mucous membrane lesions, generalised lymphadenopathy, alopecia, hoarseness, bone pain, hepatitis, nephrotic syndrome, deafness, meningitis, cranial nerve palsies
- tertiary - 20-40 years post infection
160
how is syphilis diagnosed
- early moist lessons, may be able to identify motile spirochetes on wet mount using dark ground microscopy
- serology usually positivee if ulcer present
161
what is the treatment of syphilis
penicillin by injection
| partner notification
162
which organism is most likely to cause pyelonephritis and what is the treatment
- e.coli
| - IV coamoxiclav, ciprofloxacin/cephalosporin
163
what are the symptoms and signs of AKI
symptoms
- low urine output
- confusion
- nausea and vomiting
signs
- hypertension
- distended bladder
- pericardial rub
- pallor
- rash
- bruising
164
who are the high risk patients for AKI
- elderly
- ckd
- DM
- in patients (15%)
- CCF
- myeloma
165
presence of c-ANCA and antiPR3 is suggestive of which disease
Wegeners/granulomatosis with polyangiitis
166
presence of antiGBM is suggestive of which disease
- goodpastures/ anti glomerular basement membrane antibody
| type 4 collagen
167
what is the presentation of CKD
- fatigue
- weakness
- lethargy
- restless legs
- insomnia
- muscle cramps
- pulmonary oedema
- polyuria
- headache
168
what are the complications of PKD
- hypertension
- SAH
- mitral valve prolapse
169
what are the secondary causes of nephrotic syndrome
- DM
- SLE
- amyloidosis
- NSAIDS
- myeloma
170
what are the secondary causes of nephritic syndrome
- goodpastures
- SLE
- vasculitis
- post strep throat
Phase2a
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