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IK6 - Exams > Renal and urology > Flashcards

Renal and urology Flashcards

1
Q

What cancer is aniline a RF for?

A

bladder cancer

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2
Q

What is the pathogen most common associated with haemolytic uraemic syndrome?

A

E. coli strain O157

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3
Q

what are the characteristic features of haemolytic uraemic syndrome?

A

microangiopathic haemolytic anaemia (MAHA)
acute renal failure (AKI)
thrombocytopenia

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4
Q

What are the symptoms of haemolytic uraemic syndrome?

A

profuse diarrhoea which turns bloody 1-3 days later
abdominal pain
reduced urine output
haematuria
nausea
fever
malaise
swelling/oedema

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5
Q

differentials for scrotal lumps

A
  • Scrotal skin
    • Sebaceous cyst
    • Melanoma
  • Intra-vaginal
    • Hydrocele
    • Epididymal cyst
    • Epididymitis
    • Hernia
    • Torted hydatid
  • Intra-testicular
    • Orchitis
    • Testicular abscess
    • Testicular cancer
    • Lymphoma
  • Other
    • Sarcoma of the cord
    • Lipoma of the cord
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6
Q

causes of visible haematuria (UROLOGY)

A
  • Bladder cancer
  • Infection
    • Simple UTI
    • Schistosomiasis
    • TB
  • Urinary tract calculi
  • Prostatic bleeding
  • Trauma
  • Upper tract transitional cell carcinoma
  • Renal cancer
  • Prostate cancer
  • Radiation cystitis
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7
Q

causes of transient or spurious non-visible haematuria

A
  • urinary tract infection
  • menstruation
  • vigorous exercise (this normally settles after around 3 days)
  • sexual intercourse
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8
Q

causes of persistent non-visible haematuria

A
  • cancer (bladder, renal, prostate)
  • stones
  • benign prostatic hyperplasia
  • prostatitis
  • urethritis e.g. Chlamydia
  • renal causes: IgA nephropathy, thin basement membrane disease
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9
Q

how many stages of AKI are there?

A

3

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10
Q

describe stage 1 AKI

A
  • Creatinine ↑ > 26 micromol/L within 48 hours OR
  • Creatinine risk of 50-99% of baseline within 7 days (1.5-1.99 x baseline) OR
  • Urine output < 0.5 ml/kg/hour for > 6 hours
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11
Q

describe stage 2 AKI

A
  • 100-199% creatinine rise from baseline within 7 days (2-2.99 x baseline) OR
  • Urine output < 0.5 ml/kg/hour for > 12 hours
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12
Q

describe AKI stage 3

A
  • > 200% creatinine rise from baseline within 7 days (> 3 x baseline) OR
  • Creatinine rise to > 354 micromol/L with acute rise of > 26 micromol/L within 48 hours or > 50% within 7 days OR
  • Urine output < 0.3 ml/kg/hr for 24 hours or anuria for 12 hours
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13
Q

what are the indications for dialysis?

A
  • Indications AEIOU
    • Acidosis - severe metabolic acidosis with pH < 7.2
    • Electrolyte imbalance - persistent hyperkalaemia > 7mM
    • Intoxication - poisoning
    • Oedema - refractory pulmonary oedema
    • Uraemia - encephalopathy or pericarditis
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14
Q

where does BPH hyperplasia occur? histological features

A

hyperplasia in transitional zone

increase in stromal: epithelial ratio

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15
Q

Ix for BPH

A
  • bedside
    • DRE
    • urinalysis
  • bloods
    • PSA + UE&s
  • imaging
    • bladder scan, USS KUB if concern of hydronephrosis
  • specialist
    • international prostate symptoms score (IPSS)
    • urodynamic studies
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16
Q

management of BPH

A
  • Conservative
    • Mild disease can watch-and-wait strategy
    • Bladder training - less effective if LUTS + proven outlet obstruction
    • reduce caffeine, ETOH, Tx constipation
  • Medical
    • Alpha adrenoceptor antagonist
      • Alpha blocker e.g doxazosin, tamsulosin
      • ↓ smooth muscle tone, quick effect
    • 5-alpha reductase inhibitor
      • e.g. finasteride
      • If prostate > 30g or PSA >1.4 ng/ml + high risk of progression
      • prevents dihydrotestosterone formation → ↓ prostate volume
      • longer onset
    • Dual therapy
      • Moderate-severe LUTs and prostate > 30g or PSA > 1.4ng/ml
  • Surgical
    • Indicated - severe sx, refractory
    • surgical resection to reduce prostate mass
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17
Q

what are the surgical options for BPH?

A
  • TURP
  • Transurethral incision of prostate (TUIP) if prostate < 30g but symptomatic
  • REZUM - steam vapour to shrink prostate, 30-80g prostate, IPSS > 13
  • HoLEP - holmium laser enucleates prostate, useful in very large prostates
  • Urolift - staples back lateral lobes of prostate, useful in young as ↓ retrograde ejaculation
  • Radical prostatectomy - prostate > 80g
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18
Q

types of bladder cancer + most common

A
  • Transitional cell carcinoma (urothelial carcinoma, 90%)
  • Adenocarcinoma
  • Squamous cell carcinoma - associated with schistosomiasis
  • Sarcoma
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19
Q

Ix for bladder cancer

A
  • Bedside
    • Urinalysis + MC&S
  • Bloods
    • FBC, U&Es, ALP
  • Imaging
    • CT urogram
    • multiparametric MRI - staging, indicated before TURBT
    • USS KUB - usually 1st line if non-visible haematuria
  • Specialist or scoring
    • Flexible cystoscopy - diagnostic
    • Transurethral resection of a bladder tumour (diagnostic or curative, must obtain detrusor biopsy)
      • NICE - white-like guided TURBT with photodynamic diagnostics
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20
Q

2ww rules for bladder CA

A
  • > 45 + unexplained visible haematuria w/o UTI
  • > 45 + visible haematuria that persists/recurs after UTI treatment
  • > 60 + unexplained non-visible haematuria and dysuria/↑ WCC
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21
Q

bladder cancer management

A
  • non muscle invasive
    • low risk - TURBT single intravesible mitomycin C
    • intermediate - TURBT + 6 course intravesical mitomycin
    • high risk - intravesical chemo or radical cystectomy
    • f/up with cytoscopy
  • muscle invasive
    • neoadjuvant cisplatin chemo
    • radical cystectomy or radial radiotherapy
  • locally advanced or metastatic
    • cisplatin combination chemotherapy
    • pembrolizumab (if PD-L1 +ve)
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22
Q

NICE definition of CKD

A

CKD should be diagnosed if any of the following met for more than 3 months(NICE):

  • Markers of renal damage are present such as:
    • Urinary ACR > 3mg/ml
    • Urine sediment abnormalities
    • Electrolyte or tubular disorders
    • Abnormality on histology
    • Structural abnormality on imaging
    • History of transplant
  • Persistent reduction in renal function with serum eGFR < 60
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23
Q

give the impairment of water balance seen in CKD and Sx + signs

A

Fluid overload, hypervolaemia

signs and symptoms

  • Pleural effusions (SOB, cough)
  • Pedal or sacral oedema
  • Ascites
  • Reduced urine output due to poor filtration
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24
Q

give the impairment of electrolyte homeostasis seen in CKD and Sx + signs

A

Hyperkalaemia

Cardiac dysrhythmias, palpitations

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25
Q

what is the excretion of waste impairment of function in CKD and presentation

A

uraemia

Pruritis, pericarditis, encephalopathy

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26
Q

what is the acid-base disturbance in CKD + PC

A

acidosis

N+V, tiredness

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27
Q

what is the endocrine disturbance in CKD and PC

A
  • Normocytic anaemia
    • Tired, SOB, pallor, headaches, LOC, chest pain, weakness, HF
  • Hypocalcaemia
    • Tetany, secondary hyperparathyroidism (Brown’s tumours, adynamic bone turnover), osteomalacia/osteoporosis
  • Hypertension
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28
Q

complications of CKD

A
  • ESRF, AKI (acute-on-chronic)
  • HTN, dyslipidaemia (e.g. secondary to nephrotic syndrome), CVD risk ↑ (renal osteodystrophy
  • anaemia
  • bone pain/fragility #, renal osteodystrophy (osteoporosis, necrosis + pathological #)
  • Peripheral neuropathy and myopathy incl. paraesthesia, sleep disturbance, restless leg syndrome
  • Malnutrition (ESRF) - poor intake + hypoalbuminaemia
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29
Q

management of CKD conservative

A
  • Diet - dietary advice and dietician input as required for potassium, phosphate, calorie + salt intake
  • Psychological support
  • Medication review
30
Q

medical management of CKD

A
  • Blood pressure control - managing HTN
    • ACR < 70mg/mmol target BP < 140/90 mmHg
    • ACR > 70mg/mmol target BP < 130/80 mmHg
    • 1st line
      • ACR > 30mg/mmol → ACEi or ARB
        • If DM ACEi/ARB if 3mg/mmol
      • ACR < 30 mg/mmol → following NICE pathway for HTN
  • Managing proteinuria
    • ACEi/ARB if DM ACR > 3mg/mmol OR non-diabetic + non-HTN ACR > 70mg/mmol
    • SGLT2 inhibitors offered to T2DM as dual therapy if ACR > 30mg/mmol + criteria eGFR met
  • Managing cardiovascular risk
    • Statins - 20mg for prevention
  • Optimise other health conditions
31
Q

surgical management of CKD

A

renal transplant

32
Q

management of CKD CoD - anaemia

A
  • Treat concurrent hyperparathyroidism
  • Optimise iron status
    • oral iron if not on haemodialysis
    • IV infusion if inadequate response in 3 months or on haemodialysis
  • Erythropoietin stimulating agents
33
Q

management of CKD CoD - hyperkalaemia

A
  • Acute management as per hyperkalaemia guidance
  • Patiromer - potassium binder within GI tract
    • Emergency acute life-threatening alongside standard care
    • Stage 3b-5 with CKD or HF and persistent ↑ K+ confirmed as > 6, not taking RAAS inhibitors and not on dialysis
34
Q

management of CKD CoD - hyperphosphataemia

A
  • Dietary managing under dietician
  • Phosphate binder if stage 4/5 not dialysis
    • 1st line = calcium acetate, SE - ↑ Ca2+
  • Parathyroidectomy is rarely required
35
Q

most common pathogens for epidiymitis-orchitis

A
  • < 35 → STI (chlamydia, gonorrhoea)
  • > 35 → non-sexually transmitted e.g. gram negative bacteria (E.coli, pseudomonas)
36
Q

management of epididymis-orchitis

A

Conservative

  • Advise scrotal support
  • Advise to abstain from sex is ?/confirmed STD till Tx complete

Medical

  • NSAIDS - anti-inflammatory + analgesic
  • Empirical anti-microbial therapy - 2-4 weeks
    • < 35 years old - doxycycline 100mg/12 hour to cover chlamydia + treat partners
    • Ceftriaxone 500mg/12h if suspected gonorrhoea
  • > 35 → treat for gram-negative
  • Re-assess after 3/7

Surgical - rare, if torsion can’t be excluded, abscess drain

37
Q

features of nephrotic syndrome

A

Nephrotic syndrome

  • Proteinuria (>3.5g/24h)
  • low serum albumin (<24g/L)
  • oedema
38
Q

features of nephritic syndrome

A

HTN + proteinuria + haematuria

39
Q

common causes of nephrotic syndrome

A
  • primary
    • Membranous
    • Minimal change
    • FSGS
    • Mesangiocapillary GN
  • secondary
    • Diabetes
    • SLE
    • Amyloid
    • Hepatitis B/C
40
Q

common causes of nephritic syndrome

A
  • primary
    • IgA nephropathy
    • Mesangiocapillary GN
  • secondary
    • Post streptococcal
    • Vasculitis
    • SLE
    • Anti-GBM disease
    • Cryoglobulinaemia
41
Q

IgA nephropathy vs post-streptococcal glomerulonephritis

A

IgA nephropathy → days after URTI

post-strep → weeks after URTI

42
Q

management of hydroce==

A

Congenital

  • Reassure hydrocele likely to resolve by 2 years
  • Refer if concern of underlying path., concurrent inguinal hernia, localised to spermatic cord, palpable abdominal mass

Adult

  • Urgent USS if 20-40 years of age and testis cannot be palpated
  • Conservative - watch and wait
  • Surgical
    • Must exclude CA prior to Tx
    • Aspiration - symptomatic relief, only frail + sx
    • Lord’s repair - folding of tunica vaginalis, inguinal approach
    • Jaboulay’s repair - eversion of the sac
      • Recommended for secondary non-communicating
      • Scrotal approach
43
Q

types of renal stone

A
  • calcium oxalate (MAJORITY, 85%)
    • radio-opaque
    • high Ca2+ in urine = RF
  • calcium phosphate (10%)
    • radiopaque, RTA
  • cysteine
  • uric acid (5-10%)
    • radiolucent, associated with haemolysis/tissue breakdown
  • struvite
    • Mg + ammonium + phosphate
    • urease bacteria → chronic UTI
    • staghorn
44
Q

what is the type of stone that typically causes staghorn calculus?

A

struvite

45
Q

Ix for renal calculi

A
  • Bedside
    • Abdominal examination
    • Urine dipstick - haematuria
  • Bloods
    • Renal function and U&Es
    • FBC + CRP + cultures - ?infection
    • Serum calcium - assess if contributing cause
  • Imaging
    • Non contrast CT KUB - diagnostic imaging of choice
      • Urgent, within 24 hours of presentation
46
Q

management of renal stones

A

Conservative

  • Watchful waiting - stones < 5mm, no sx of obstruction

Medical

  • Analgesia
    • 1st line - NSAIDs, PR/IM diclofenac (75mg diclofenac IM)
    • 2nd line - IV paracetamol
    • Consider opioids
  • Alpha blockers - tamsulosin, alfuzosin
    • Indications - distal stone < 10mm

Surgical

  • Percutaneous nephrolithotomy
    • Indicated: stones > 2 cm, complex stones (staghorn, cysteine)
    • Retrograde ureteral catheter, cystoscopy, stone collected
  • Ureteroscopy
    • 1st line for _distal/middle ureteric stone_s, pregnant women
  • Shock wave lithotropsy
  • Open stone surgery
    • <1% o
    • Indications: failed Tx, complex/staghorn calculi, morbid obesity, complex renal/ureteric anatomy
47
Q

when to admit someone with renal stones?

A
  • Shock or signs of systemic infection
  • ↑ risk of AKI e.g. pre-existing CKD or solitary/transplanted kidney or bilateral stones suspected
  • Dehydrated and not tolerating oral fluids
  • Uncertainty of diagnosis
48
Q

General management of nephrotic syndrome

A

General for adults 1. Sodium and fluid restriction 2. Diuretic treatment - furosemide 3. High dose steroids part of Tx for most. Good response in kids, less predictable in adults ACEi - can be used in less treatment-responsive adults

49
Q

management of overactive bladder

A
  • conservative
    • bladder training - 6/52
    • fluid management
    • pelvic floor exercises 8 TDS, 3/12
  • medical
    • anticholinergics - oxybutynin, tolterodine
    • mirabegron - beta-3 adrenergic agonist, 2nd or dual
  • surgical
    • neurotoxin botulinum toxin A
    • neuromodulation - perc. sacral or post. tibial nerve stimulation
    • augmented cystoplasty
    • urinary diversion (urostomy)
50
Q

types of polycystic kidney disease

A
  • type 1 - AD, adult
    • Ch16 (85%) - ESRF by 50s
    • Ch4 (15%) - ESRF by 70s
    • 1 in 1000
  • type 2 - AR, children
    • rare
    • Ch6, early presentation with renal + hepatic cysts
51
Q

histological types of prostate cancer

A
  • adenocarcinoma (most common, peripheral zone)
  • TCC
  • SCC
  • small cell prostate cancer
52
Q

RF for prostate cancer

A
  • Non-modifiable = African ethnicity, FHx +ve, BRCA mutation, ↑ age
  • Modifiable = Obesity, smoking, diet (high in animal fats and milk products)
53
Q

2WW for prostate cancer

A

Indicated:

  • DRE reveals hand, nodular prostate
  • PSA > 3 nanogram/mL and ages 50-69
54
Q

Ix for prostate cancer

A
  • Bedside
    • Digital rectal examination
    • Urine dipstick
  • Bloods
    • PSA:
      • Normal 0-4
      • 50-69 and if > 3nanogram/mL refer via 2WW
    • bone profile (including calcium)
    • FBC, U&Es, acid phosphatase, LFTs, U&Es
  • Imaging
    • CT/MRI + isotope bone scan: staging
      • Multiparametric MRI only if for radical treatment
  • Specialist or scoring
    • Transrectal USS + needle biopsy: abnormal cells in 2 different samples → malignancy diagnosis
55
Q

management of prostate cancer

A
  • low risk, Gleason < 7
    • active surveillant
    • radical prostatectomy
    • radical radiotherapy
  • intermediate + local. 8+
    • hormone therapy
    • radical prostatectomy
    • radiotherapy
    • docetaxel chemotherapy
  • metastatic
    • hormonal treatment
    • GnRH agonist + 3/52 anti-androgen
      • goserelin
      • anti-androgen - flutamide, cyproterone acetate
56
Q

what is the gleason score?

A
  • prostate cancer
  • histology is graded from 1-5 from 2 biopsies and added together
  • < 6 is low, 7 - intermediate, > 8 is high risk
57
Q

causes of renal artery stenosis

A
  • atherosclerosis
  • fibromuscular dysplasia (< 50)
  • VTE
  • compression by external mass
58
Q

types of renal cell cancer

A
  • clear cell (70%, most common)
    • epithelial renal tumour with clear cell sets in capillary network
    • associated with VHL
  • papillary (15%)
    • epithelial tumour of papillae + tubules
  • chromophobe RCC
    • well circumscribed brown tumour
59
Q

what is the histological type of RCC associated with long-term dialysis?

A

papillary

60
Q

management of RCC

A
  • localised
    • resection - partial if < 7cm, radial otherwise
    • + chemotherapy + radiotherapy
  • advanced or metastatic
    • radial nephrectomy + biological treatment
      • interferon alpha, IL2
61
Q

management of stress incontinence

A
  • conservative
    • pelvic floor exercise 8 TDS, 3 months
    • fluid intake
    • reduce weight, optimise DM, Oestrogen if post-M
  • medical - 2nd line, non surg. candidate
    • duloxetine
    • desmopressin - nocturia specifically
  • surgical
    • colposuspension
    • autologous rectus fascial sling
    • intramural bulking agents
    • artificial urinary sphincter
62
Q

types of testicular cancer

A
  • Germ cell tumour (95%)
    • Seminoma (50%)
      • ↑ HCG + lactate, or normal
    • non-seminoma - AFP and beta-HCG usually raised
      • Teratoma
      • Embryonal carcinoma
      • Yolk sac tumour
      • Choriocarcinoma
    • Mixed seminoma-teratoma
  • Non-germ cell tumour (5%)
    • Sertoli
    • Leydig
  • Sarcoma
  • Non-Hodgkin’s lymphoma
63
Q

Ix for testicular cancer

A
  • Bedside
    • Scrotal examination
  • Bloods
    • Serum beta-HCG
    • Serum alpha fetoprotein
    • Serum lactate
    • Basics - FBC, U&Es
  • Imaging
    • Scrotal USS - visualisation of mass
    • CT CAP - assessment for metastases
    • CXR - assess for mets, cannonball
  • Specialist or scoring
    • Sperm banking

*don’t biopsy as risk of seeding, automatic upgrade of stage

64
Q

management of testicular cancer

A
  • Radical orchidectomy + lymph node dissection + prosthesis
    • Inguinal orchidectomy (not scrotal)
    • + chemotherapy
      • Chemotherapy = mainstay
      • Indicated: higher stage disease (metastatic), high risk
      • Low risk - carboplatin regime
      • High risk - BEP combination (bleomycin, etoposide, platinum - cisplatin), usually 3 cycles
    • + radiotherapy - external beam radiation
65
Q

summary of testicular cancer management

A
66
Q

what is a varicocele?

A

Abnormal dilation of the internal spermatic veins and pampiniform plexus which drains into the testis.

67
Q

what side is a varicocele more common?

A

More common on the left due to the angle at which the left testicular vein meets left renal vein means there are no effective valves and therefore ↑ reflux from compression of renal vein by SMA and aorta

68
Q

Ix for varicocele?

A
  • Bedside
    • Scrotal examination
  • Bloods
    • Serum FSH and testosterone
  • Imaging
    • Doppler USS - confirms diagnosis
  • Specialist or scoring
    • Semen analysis - if presenting with concurrent fertility concerns, common cause of subfertility
    • RCC screen if rapid onset/older/Sx CA
69
Q

management of varicocele

A
  • Conservative
    • If mild, aSx, normal semen analysis
    • Observation
  • Referral to secondary care - if:
    • Sudden onset > 40 years of age and remains tense on lying down - urgent
    • Single right-sided varicocele - urgent
    • Uncertainty about diagnosis
    • Routinely causing pain or discomfort
    • In adolescents consider
  • Surgical
    • aim to ligate veins to prevent abnormal flow
    • Open or laparoscopic repair - ligation of vessels affected
    • Percutaneous embolisation
70
Q

complications of TURP

A

T - TURP syndrome

U - urethral stricture/ UTI

R - retrograde ejaculation

P - perforation of the prostate

IK6 - Exams (24 decks)

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