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Phase 2 Quick > Renal & GU > Flashcards

Renal & GU Flashcards

1
Q

Tx of BPH

A

Tamsulosin
Finasteride

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2
Q

Action of tamsulosin
& what class of drug is it?

A

Relax smooth muscle of bladder and prostate
∴ ↑ Urine flow rate

(selective alpha-1-adernergic receptor antagonists)

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3
Q

S/E of tamsulosin

A

Postural instability, retrograde ejaculation

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4
Q

Findings on DPE of BPH

A

Smooth, enlarged prostate

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5
Q

Findings of DPE of Prostate cancer

A

Hard and irregular

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6
Q

Ix for BPH
(incl values if measuring any antigens cough cough)

A

Digital Rectal Examination
Prostate-Specific antigen > 1.5ng/mL
GS (?) : Trans-rectal US

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7
Q

Ix for Prostate cancer
(no abbrv)

A

Digital Rectal Exam
Prostate Specific Antigen
Trans-rectal US
Prostate biopsy

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8
Q

What’s the grading thing called for prostate cancer?

A

Gleason grading score

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9
Q

Most common pathogens for UTIs

A

E.Coli
Proteus

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10
Q

Why is creatinine used as a marker of GFR?

A

Freely filterised
Not metabolised
Not secreted
Not reabsorbed

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11
Q

Mechanism of loop diuretics
Where do they act upon?

A

Act of ascending limb of loop of Henle

Inhibit Na+/K+/2Cl- co-transporter
(bc if it transports ions, water will follow)

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12
Q

Examples of loop diuretics

A

Furosemide
Bumetanide

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13
Q

S/E Loop diuretics

A

Dehydration
Hypotension
Hypokalaemia
& Metabolic alkalosis can occur !

If v high doses, can cause ototoxicity

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14
Q

Give an example of K+ sparing diuretic

A

Amiloride
Spironolactone

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15
Q

Mechanism of K+ sparing diuretics
Where do they act upon?

A

Act on the distal convoluted tubule

Inhibits reabsorption of sodium (and ∴ water) by epithelial sodium channels
∴ Na+ and H2O excretion
(and K+ retention)

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16
Q

S/E K+ sparing diuretics

A

GI upset
Hyperkalaemia
Metabolic acidosis
Gynecomastia

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17
Q

Example of a thiazide diuretic

A

Bendroflumethiazide

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18
Q

Mechanism of Thiazide diuretic
Where does it act upon?

A

Acts on sodium/chloride transporter
Prevents it from functioning properly

∴ Sodium is NOT retained

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19
Q

Compare thiazide and loop diuretics
(In terms of length and efficacy)

A

Thiazide diuretics are longer acting
But not as effective as loop

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20
Q

S/E Thiazide diuretics

A

Hypokalaemia
Metabolic alkalosis
Hypovolaemia
Hyponatraemia

Hyperglycaemia in DM

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21
Q

Where does Angiotensin II act on?

A

PCT

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22
Q

What does Angiotensin II do?

A

Causes thirst
↑ SNS activity
ADH release (by stimulating post. pituitary)
Aldosterone release (by stimulating adrenal glands)
↑Proximal tubule reabsorption which ↑Na+ reabsorption
Causes vasoconstriction to ↑BP

ESSENTIALLY, ↑BP

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23
Q

Where does Aldosterone act?

A

On DCT and collecting ducts

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24
Q

What does Aldosterone do?

A

↑Na+ reabsorption
↑K+ secretion
Binds to cytoplasmic receptors - transported to nucleus
↑Epithelial Na channels
↑Na+/K+ ATPase
↑Effective circulating vol

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25
Q

Where does ADH act on?

A

Distal tubule
Collecting ducts

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26
Q

What does ADH do?

A

Acts on V1 receptors on blood vessels to cause vasoconstriction
Acts on V2 receptors in basolateral side of collecting ducts

↑ Insertion of aquaporin 2 on apical membrane of collecting ducts
∴ ↑ Water reabsorption

Also, helps maintain hypertonicity of medulla by ↑urea permeability of collecting ducts

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27
Q

What is ADH produced by?

A

Hypothalamus

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28
Q

Where is ADH released?

A

Post. pituitary

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29
Q

What triggers ADH release?

A

Increased plasma osmolality
(↓ water)

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30
Q

What detects decreased water in the body? How?

A

Hypothalamic osmoreceptors
Detects bc H2O diffuses out post. pituitary in response to ↑Na+ pulling it out

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31
Q

What is ANP?

A

Atrial Natriuretic Peptide

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32
Q

What is the aim of ANP?

A

To decrease BP
(inhibits renin secretion)

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33
Q

When is ANP released ?

A

When atria are stretched (due to high BP), it causes ANP to be released

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34
Q

What are the actions of ANP?

A

Dilates aff glomerular arterioles
Constricts eff glomerular arteriole

Relaxes mesangial cells (to ↑GFR) - so excretion can be increased

“Blocks” NCC in DCT and ENaC in CT
∴ prevents reabsorption and ↑Na+ excretion

↑Vasa recta blood flow - leads to less reabsorption

SYSTEMIC VASODILATOR

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35
Q

Where is parathyroid hormone released from?
In response to what?

A

Parathyroid glands
In response to ↓Ca2+ plasma levels

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36
Q

What does PTH do?

A

↑ Ca2+ reabsorption
↑ HPO4^3- excretion
Stimulates formation of Vit D

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37
Q

Describe the activation of Vitamin D

A
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38
Q

Where can kidney stones be deposited?

A

Anywhere from renal pelvis to ureter

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39
Q

Where are kidney stones formed?

A

Collecting ducts

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40
Q

RF Renal Colic

A

Male (M:F 2:1)
Middle East - due to higher oxalate, lower Ca2+ diet and ↑dehydration

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41
Q

What is renal colic also known as?

A

Nephrolithiasis

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42
Q

Where the most common sites for renal stones to get stuck?

A

Pelviureteric junction (PUJ) - MC !

Pelvic brim
Vesicoureteric junction (VUJ)

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43
Q

Causes Renal Colic

A

ANATOMICAL ABNORMALITIES
Congenital - horseshoe, duplex, PUJ, spina bifida
Acquired - obstruction, trauma, reflux

URINARY
Metastable urine
Ca2+, oxalate, urate, cystine
Dehydration

INFECTION-INDUCED STONES (struvite) - UTI w organisms that produce urease, is assoc/ with struvite stones
Proteus, klebsiella, pseudomonas

HYPERCALCIRURIA
In turn, caused by:
Hyperparathyroidism - MC !!!
Hypercalcaemia
XS dietary calcium
XS resorption of calcium from bone (immobilisation)
Idiopathic hypercalciuria

HYPEROXALURIA
↑ dietary intake of oxalate rich foods e.g. spinach, rhubarb, tea
ALSO, ↓dietary calcium intake
(bc means decreased binding of oxalate w/ Ca2+)

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44
Q

Signs / Symptoms Renal Colic

A

Can be asymptomatic

Loin to groin colicky pain - peristaltic waves
Severe, unilateral, worse than labour!
Rapid onset (mins-hours)
Unable to get comfy - writhing in agony
Worse w fluid loading

N+V
Sweating
Fever

UTI Sx !! - Dysuria, burning when urinating, urgency, frequency

Haematuria (visible and non-visible)
Recurrent UTIs
Rigors
Bladder/urethral stones

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45
Q

Ix Renal Coli

A

Detailed history - might reveal cause of stone e.g. lots of tea = high oxalate

1st line - XR KUB
(easy and cheap)

GS!!! NON-CONTRAST CT KUB
vvv spec (99%)

US - useful for pregnancies and young (no radiation)
Sens for hydronephrosis

Urine dipstick - traces of blood
Mid-stream specimen
follow up with MSU if pos

Bloods - FBC, U&E, calciu, uric acid

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46
Q

What benefits does Non-Contrast CT have over CT w contrast?

A

Good for allergies (doesnt trigger)
and no renal damage

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47
Q

Tx Renal Colic

A

Hydration

STRONG ANALGESIC - IV diclofenac
NSAIDs, IV paracetamol, +/- opiates!

Anti-emetics - metoclopramide

+/- IV fluids - might make pain worse as diuresis happens

Conservative - allow 2 weeks to pass

Abx if UTI

Medical expulsive therapy? Not much evidence if it works

Extracorpeal Shock Wave Lithotripsy (ESWL) - if <1 cm

Surgery - Ureteroscopy, Percutaneous Nephrolithotomy (PCNL), Nephrectomy

ADMIT IF SHOCK, FEVER, SEPSIS, PREGNANCY ETC

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48
Q

Types of Stones

A

Calcium oxalate - form in acidic urine, MC !!!!

Calcium phosphate - alkali urine
Calcium carbonate
Struvite - proteus, Klebsiella, pseudomonas bacteria

Uric acid
Cystine
Drug precipitants

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49
Q

Why are Kidney stones treated more conservatively?

A

Small, safe location
More asymptomatic
Static size

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50
Q

Lifestyle changes for prevention Renal Colic

A

↓Dietary salt
Normal dairy intake
Lose weight
Active lifestyle
Overhydration
Stop smoking
More citrus fruit

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51
Q

With renal colic, when might a stone pass spontaneously?

A

If small <5mm

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52
Q

How might you treat renal colic if it’s a large stone?

A

ESWL
Ureteroscopy
PCNL

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53
Q

Comps Renal Colic

A

HYDRONEPHROSIS - requires surgical drainage

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54
Q

AKI Criteria for diagnosis

A

↑ Creatinine > 26 mmol/L in 48 hours above baseline

↑ Creatinine > 50% (best fig in last 6 months)

Urine output < 0.5ml/kg/hour for > 6 consec hours

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55
Q

Define AKI

A

Abrupt deterioration (hours to days) in renal function
Due to rapid decline in GFR
Leading to a failure to maintain fluid, electrolyte, acid-base homeostasis
Usually but not always reversible

Decreased in function < 3 months?

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56
Q

What is AKI assoc with?

A

Diarrhoea
Haematuria
Haemoptysis
Hypotension
Urine retention

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57
Q

Causes AKI

A

PRE-RENAL - ↓blood flow to kidney ∴ ↓ GFR
Shock
Hypovolaemia ! - diarrhoea, vomiting, trauma, bleeding, diuretics, burns
Hypotension - cardiogenic shock, sepsis, anaphylaxis
Cardiovascular - HF, severe arrhythmias
Sepsis
Renal hypoperfusion - NSAIDs, ACEi, ARBs

RENAL - cells damaged so kidney can’t filer blood properly
Acute tubular necrosis
Nephrotoxins - NSAIDs, Methotrexate
Glomerulonephritis
Acute interstitial nephritis
Infection
Vasculitis
Malignant HTN
Autoimmune disease

POST-RENAL - anything that causes blockage of kidney
BPH
Kidney stones
Cancer
Blood clot

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58
Q

RF AKI

A

Age > 75 years
DM
HF
Sepsis
Peripheral vascular disease
Drugs
FHx
Poor fluid intake/loss

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59
Q

DDx Nephrolithiasis

A

Aortic abdo aneurysm
Diverticulitis - L sided
Appendicitis - R sided
Pyelonephritis
Acute pancreatitis
Ectopic preg
Testicular torsion
Peritonitis

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60
Q

Signs / Symptoms AKI

A

Often asymptomatic!! Esp early stages

Fluid overload - oliguria/anuria, pulmonary/peripheral oedema, palpable bladder, hypovolaemic shock, ↑JVP,

Hyperkalaemia - arrhythmias, muscle weakness, tachycardia

Hyperuraemia - N+V, weakness, tremor, pericarditis, platelet dysfunction (bleeding), confusion and seizures if severe

Metabolic acidosis
Postural hypotension
Thirst
Poor tissue turgor

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61
Q

When is AKI a medical emergency?

A

Hyperkalaemia!!

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62
Q

What ECG signs are associated with hyperkalaemia?

A

Tall peaked T waves
Wide QRS
Small P waves

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63
Q

Ix AKI

A

Urine dipstick - blood, nitrites, leukocytes, glucose, protein

Bloods - FBC, U&Es, creatinine, liver enzymes

Renal US - for obstruction
Renal biopsy - for intra renal cause

Monitor urine output

Non-contrast CT KUB
KUB CR

Autoantibodies - Anti-GBM, ANCA

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64
Q

Tx AKI

A

Treat underlying cause
Pre-renal - correct vol depletion w fluids, treat sepsis w Abx

Intra-renal - maybe refer if concern over glomerular/interstitial pathology

STOP NEPHROTOXIC DRUGS ! - NSAIDs, ACEi, ARBs, lithium, digoxin

Treat underlying comps - hyperkalaemia, pulmonary oedema etc

IF severe - dialysis

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65
Q

What is refractory pulmonary oedema?

A

When AKI is esp bad, kidneys stop producing urine
That fluid can end up in lungs!

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66
Q

Describe some differences between AKI and CKD

A

AKI
Normal sized kidneys
No anaemia
No DM
↓ BP
Rapid change
Oliguria usually
Not often CNS symptoms
Presents more like shock

CKD
Small kidneys!
Anaemia
DM
↑BP
Gradual onset
Oliguria only in later stages
CNS symptoms in later disease
Presents like serious extensive disease

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67
Q

Chronic Kidney Disease Definition

A

Long-standing and progressive pathological abnormality of the kidney FOR AT LEAST 3 MONTHS

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68
Q

Pathophysiology Renal Colic

A

Stones form from crystals in supersaturated urine
Occurs when solute is too conc - increase in solute or decrease in solvent (dehydration)

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69
Q

Causes CKD

A

HTN
DM (more T2 than T1)
Polycystic kidney disease
SLE
Nephrotoxic drugs, chronic NSAID use
Obstructive uropathy - kidney stones, enlarged prostate

Progression from AKI
Glomerular disease / Chronic glomerulonephritis
SLE
Atherosclerotic renal vascular disease
Tuberous sclerosis
Malignancy - myeloma

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70
Q

CKD Diagnostic Criteria

A

eGFR < 60 ml/min/1.73m2

eGFR < 90ml/min/1.73m2 + signs of renal damage

Albuminuria > 30mg/24hours
(albumin:creatinine > 3mg/mmol)

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71
Q

RF CKD

A

DM
HTN
Female?
Age
Smoking
Polycystic kidney disease
NSAIDs
Cardiovascular disease - IHD, LV hypertrophy
FHx

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72
Q

Signs / Symptoms CKD

A

Early stages = Asymptomatic
Arise as GFR declines
–
Urinary - oliguria! haematuria, proteinuria, nocturia, polyuria

Bone disease! - Osteomalacia, osteoporosis

Anaemia!

Bilaterally small kidneys!!

Increased skin pigmentation! (yellow tinge)

HYPERKALAEMIA

N+V, fatigue, malaise, anorexia, itching, hiccups, convulsions, tremors, pallor

CVD - Uraemic pericarditis

Neuro - confusion, coma, fits

Vol overload - SOB (pulmonary oedema, dyspnoea, ankle oedema)

Sexual dysfunction

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73
Q

Describe the mechanism of HTN as a cause for CKD

A

Walls thicken in order to withstand pressure
∴ narrow lumen
∴ less blood and O2 to kidney
∴ ischaemic injury

Immune cells travel into damaged glomerulus and release TGF-B1
Then, mesangial cells regress to immature cells + excrete extracellular matrix
∴ GLOMERULOSCLEROSIS (kidney is scarred)
∴ ↓ ability for nephron to filter blood

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74
Q

Describe the mechanism of DM as a cause for CKD

A

Type 2 > Type 1

XS glucose in blood sticks to proteins - esp effects efferent arteriole making it stiff and narrow

∴ obstruction for blood leaving glomerulus
∴ hyperfiltration
∴ mesangial cells secrete more structural matrix
∴ ↑ size of glomerulus
∴ Glomerulosclerosis
Eventually becomes CKD

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75
Q

Quick!!!! Presentation CKD

A

Early asympto
Normochromic, normocytic anemia
Bone disease ! - osteomalacia
HTN
Fluid overload - oedema
CVD - cardiomyopathy
Malaise, loss of appetite, oliguria, haematuria

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76
Q

Ix CKD

A

FBC - shows anaemia, ↑ creatinine and urea levels
+ ↓ Ca2+ , ↑ phosphate, PTH, K+

Urinalysis
Dipstick (haematuria and proteinuria ~ GN, leukocytes and nitrites ~ infection)

Urine & blood culture - to exclude infection
White cells - bacterial UTI
Eoisinophilia - allergic tubulointerstitial nephritis
Granular casts - active renal disease
Blood - glomerulonephritis

Renal US - excludes obstruction, see kidney size!

CT - useful to diagnose retroperitoneal fibrosis and other causes of obstruction

Biopsy
Cystoscopy
ECG - hyperkalaemia

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77
Q

Tx CKD

A

Irreversible so aim is to prevent progression and symptom control!

If eGFR < 30 OR A:C > 70 = stage 4. Refer to nephrology
Lifestyle changes!

Treat underlying cause!

HTN - treat w ABCD etc
Oedema - fluid and sodium restriction, loop diuretic
DM - metform etc
CVD - aspirin, atorvastatin (statins if GFR < 60)

If all else fails - Renal replacement therapy (haemo/peritoneal dialysis, kidney replacement, haemofiltration)

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78
Q

Describe the stages of CKD

A

Stage 1 - eGFR ≥ 90 (mild damage, kidneys work as normal)

Stage 2 - eGFR 60 - 89 (mild damage, kidneys still work well)

Stage 3a - eGFR 45 - 59 (mild-mod damage, kidneys don’t work as well as they should)

Stage 3b - eGFR 30 - 44 (Mod-severe damage, kidneys don’t work as well as they should)

Stage 4 - eGFR 15 - 29 (Severe damage, close to not working at all)

Stage 5 - eGFR is less than 15! (close to not working at all or have failed, most severe damage)

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79
Q

What are some indications for dialysis?

A

Symptomatic uraemic - pericarditis or tamponade

Hyperkalaemia - when not controlled by conservative means

Metabolic acidosis

Fluid overload - resistant to diuretics

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80
Q

Comps CKD

A

Hyperkalaemia
Osteoporosis !
Vit D def
Anaemia
Metabolic acidosis
Pruritus - bc nitrogenous waste products of urea
Pericarditis
HTN

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81
Q

Quick!
Loin pain, Fever, Pyuria
What is it?

A

Pyelonephritis

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82
Q

Ix ALL UTIs

A

1st line - Urine dipstick
Will be +leucocytes, + nitrites, +haematuria

GS!!! Midstream microscopy, culture and sensitivity

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83
Q

Pathophysiology Benign Prostate Hyperplasia

A

Benign proliferation of transitional zone of prostate!

After 30 - men produce 1% less testosterone every year but 5a-reductase increases
∴ ↑ dihydrotestosterone levels
∴ prostate cell hypertrophy

As prostate grows, can squeeze/block bladder
∴ urine retention
∴ bladder dilation and hypertrophy
∴ urine stasis
∴ bacteria
∴ UTI !

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84
Q

Cause BPH

A

Dihydrotestosterone

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85
Q

RF BPH

A

Age
FHx
Heart disease
Obesity
DM

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86
Q

What is protective against BPH?

A

Castration!

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87
Q

Signs / Symptoms BPH

A

STORAGE
Frequency ↑
Urgency
Nocturia
Urgency incontinence

VOIDING - SHIPP
Straining
Hesitancy
Incomplete emptying
Poor/intermittent stream
Post-micturition dribbling

–
Bladder stones
Acute urinary retention
UTIs

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88
Q

Red flags for prostate cancer

A

Dysuria - painful/difficult urination
Haematuria

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89
Q

Painless haematuria
What are you instantly assuming it is?

A

Malignancy
Until proven otherwise

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90
Q

DDx BPH

A

Overactive bladder syndrome!
Bladder tumour
Bladder stones
Trauma
Prostate/Bladder cancer
UTI
Prostatitis

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91
Q

Ix BPH

A

International prostate symptom score (IPSS)
Digital rectal exam - smooth, enlarged prostate

PSA - may be raised
Urine dipstick
Biopsy
Abdo exam = enlarged bladder

To exclude renal damage - U&E and renal US
Also to rule out obstruction - US

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92
Q

Tx BPH

A

Lifestyle advice - avoid caffeine and alcohol
Void twice in a row to aid emptying

1st line - oral tamsulosin
2nd line - oral finasteride, dutasteride

Surgery - GS!
Trans-urethral resection of prostate (TURP)
or Trans-urethral incision of prostate (less destruction, best for small prostates)

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93
Q

What are some indications BPH should be treated with surgery?

A

RUSHES
Retention
UTIs
Stones
Haematuria (resistant to 5-alpha reductase-inhibitors i.e. FInasteride)
Elevated creatinine
Symptom deterioration

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94
Q

Comps TURP

A

Risk of ED

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95
Q

Comps BPH

A

Bladder calculi
UTI
Haematuria
Acute retention

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96
Q

Causes UTI

A

KEEPS

Klebsiella
E.Coli
Enterobacter
Proteus / Psuedomonas aeruginosa
Staph spp

97
Q

What is Klebsiella often assoc with?

A

Hospitals
Catheters

98
Q

Which KEEPS bacteria for UTIs is most common?

A

E.Coli !

99
Q

What is Proteus assoc with?

A

Renal stones

100
Q

What is Pseudomonas aeruginosa assoc w?

A

Recurrent UTIs

101
Q

A young, sexually active female has a UTI. Which bacteria is it most likely to be?

A

Staphylococcus spp

102
Q

Name Lower UTIs

A

Cystitis
Prostatitis
Urethritis
Epidydymo-orchiditis

103
Q

Name Upper UTIs

A

Pyelonephritis

104
Q

What causes a UTI to be complicated?

A

Pregnancy
Males
Catheterised patients
Children
Recurrent or Persistent infection
Immunocomp
If acquired in hospital (Nosocomial)
Urosepsis

105
Q

Signs / Symptoms Lower UTI

A

HD FUSS

Haematuria
Dysuria

Frequency
Urgency
Suprapubic pain
Smelly urine

106
Q

Signs / Symptoms Upper UTI

A

Loin/Abdo pain
Tenderness
N+V
Fever
Costovertebral angle pain

107
Q

Why do you do midstream urine sample?

A

Bc first sample of urine has first shedding of epithelial cells
Want to void bacteria away to get fresh part

108
Q

Why might you get a urine sample first thing in the morning?

A

Because bacilli accumulate in urine and after a period of dehydration, you will tend to get the highest conc

109
Q

Signs / Symptoms Pyelonephritis

A

TRIAD OF : Loin pain, fever, pyuria
Usually unilateral pain

+
Back pain
Headaches
N+V
Rigors
Costovertebral angle pain
Assoc cystitis symptoms

110
Q

What is Pyelonephritis?

A

Infection of renal parenchyma and soft tissues of renal pelvis and upper ureter

111
Q

Route of infection for Pyelonephritis

A

Infection usually bc E.Coli (UPEC)

Usually via ascending transurethral route
BUT can be via bloodstream or lymphatics (L = rare)
–
Haematogenous - Aureus, Candida

112
Q

DDx Pyelonephritis

A

Diverticulitis
Abdo aortic aneurysm
Kidney stones
Cystitis
Prostatitis

113
Q

Tx Pyelonephritis

A

Hydration / Fluid replacement
Analgesia!

Co-amoxiclav for 7 days / Trimethoprim for 14 days
+/- Gentamicin if severe
IF PREGNANT, cefalexin for 7 days

IV if severe

Drain obstructed kidney

114
Q

Who does Cystitis occur in?

A

Children
Females
Pregnant
Catheterised

115
Q

Why are women more susceptible to UTIs?

A

Shorter urethra
Short proximity to anus - allows bacteria transfer

116
Q

Signs / Symptoms Cystitis

A

HD FUSS
Haematuria
Dysuria

Frequency
Urgency
Suprapubic pain
Smelly urine

+ Incontinence
+ Confusion in elderly

117
Q

What drugs are Nephrotoxic?

A

ACEi
ARBs
NSAIDs
Digoxin
Lithium

118
Q

What is cystitis?

A

Urinary infection of the bladder

119
Q

Causes Cystitis

A

KEEPS
Mostly E.Coli

120
Q

Tx Cystitis

A

1st line - Nitrofurantoin or Trimethoprim

If pregnant! Trimethoprim CANNOT be used in 1st trimester and Nitrofurantoin CANNOT be used in 3rd trimer
∴ use cefalexin (or amoxicillin) instead

2nd line - Ciprofloxacin or co-amoxiclav

121
Q

What is Prostatitis?

A

Infection and inflammation of prostate gland

122
Q

Causes Prostatitis

A

Acute - Strep. Faecalis, E.Coli, Chlamydia

Chronic :
Bacterial - Strep. Faecalis, E. Coli, Chlamydia
Non-Bacterial - Elevated prostatic pressure, pelvic flood myalgia

123
Q

RF Prostatitis

A

STI
UTI
Indwelling catheter
Post-biopsy
Age ↑

124
Q

Signs / Symptoms Prostatitis

A

ACUTE :
Systemic symptoms
Fevers, rigors, malaise
Painful ejaculation
Pelvic pain
HD FUSS

CHRONIC :
Acute symptoms > 3 months
Recurrent UTIs

125
Q

DDx Prostatitis

A

Cystitis
BPH
Calculi
Prostatic abscess
Malignancy

126
Q

Ix Prostatitis

A

the normal PLUS

DRE - prostate = tender, hard from calcification

Blood cultures
STI screen - esp chlamydia
Trans-urethral US scan (TRUSS)

127
Q

Tx Prostatitis

A

ACUTE :
1st line - IV gentamycin + IV co-amoxiclav

2nd line - Trimethoprim

TRUSS abscess drainage if necessary
4-6 weeks quinolone etc once well
–
CHRONIC :
4 - 6 weeks of quinolone e.g. ciprofloxacin
+/- alpha-blocker (tamsulosin)

128
Q

Comps Prostatitis

A

Urinary retention

129
Q

What is urethritis?

A

Urethral inflammation

130
Q

Causes of Urethritis

A

GONOCOCCAL - Neisseria gonorrhoea

NON-GONOCOCCAL -
Chlamydia MC !
Mycoplasma genitalium
Trichomonas vaginalis

NON-INFECTIVE -
Trauma
Urethral stricture
Irritation
Urinary calculi

131
Q

RF Urethritis

A

Sexually active
Unprotected sex
Male 2 Male sex

132
Q

Signs / Symptoms Urethritis

A

May be asymptomatic

Systemic Sx - malaise, fatigue etc
Dysuria
Discharge, blood, pus
Urethral pain
Penile discomfort
Skin lesions

133
Q

DDx Urethritis

A

Candida balanitis
Epididymitis
Cystitis
Acute prostatitis
Urethral malignancy

134
Q

Ix Urethritis

A

Normal UTI Ix
PLUS

Nucleic Acid Amplification Test (NAAT)
high spec, high sens
F - self-collected vaginal swab, endo-cervical swab, first void urine
M - first void urine

Urine dipstick - to exclude UTI (bc primarily a SEXUALLY ACQ DISEASE)

Urethral smear

135
Q

Tx Urethritis

A

Chlamydia :
PO azithromycin or 1week doxycycline PO
IF PREGNANT - PO erythromycin (14days) or PO azithromycin

Gonorrhoea
IM ceftriaxone w/ PO azithromycin
Partner notification
–
Patient ed
Contact tracing

136
Q

What do you need to keep in mind with urethritis?

A

Reactive arthritis
- can’t see, can’t pee, can’t climb a tree

137
Q

When is Epididymo-Orchitis most common?

A

15 - 30 years
> 60 years

138
Q

Causes Epididymo-Orchitis

A

STIs :
< 35 years
Chlamydia trachomatis
Neisseria gonorrhoea

> 35 years
KEEPS
–
Mumps
Trauma
Elderly - usually catheter related

139
Q

Signs / Symptoms Epididymo-Orchitis

A

Scrotal pain and swelling! - subacute onset, unilateral
Tenderness
Sweats/fevers

If STI cause : Urethritis, Urethral discharge

If Mumps cause : Headache, fever, unilateral or bilateral parotid swelling

140
Q

Ix Epididymo-Orchitis

A

Normal UTI Ix
PLUS

Nucleic Acid Amplification Test (NAAT)
high spec, high sens
F - self-collected vaginal swab, endo-cervical swab, first void urine
M - first void urine

Urine dipstick - to exclude UTI (bc primarily a SEXUALLY ACQ DISEASE)

Urethral smear

141
Q

Quick!
Genital ulcer, what is the disease?

A

ANY GENITAL ULCER IS SYPHILIS UNTIL PROVEN OTHERWISE

142
Q

Quick!
Testicular lump, what is it?

A

Cancer until proven otherwise

143
Q

Quick!
Acute and tender lump, what is it?

A

Testicular torsion until proven otherwise

144
Q

Big 3 Qs to ask about scrotal masses

A
  1. Can you get above it?
  2. Is it separate from testis?
  3. Cystic or solid?
145
Q

Scrotal mass : Cannot get above
What is it?

A

Inguinoscrotal hernia
OR
Proximally extending hydrocele

146
Q

Scrotal mass : Separate AND cystic
What is it?

A

Epididymal cyst

147
Q

Scrotal mass : Separate AND solid
What is it?

A

Epididymitis
OR
Varicocele

148
Q

Scrotal mass : Testicular AND cystic
What is it?

A

Hydrocele

149
Q

Scrotal mass : Testicular AND solid
What is it?

A

Tumour, haematocele

150
Q

Describe an Epididymal cyst

A

Smooth, extratesticular, spherical cyst in head of epididymis

151
Q

What does an epididymal cyst contain?

A

Clear and milky (spermatocele) fluid

152
Q

Signs / Symptoms Epididymal cyst

A

Can be painful once large
Lump - often multiple and bilateral
Well defined
Will transluminate
Testis palpable SEPARATE from cyst

153
Q

How do differentiate between epididymal cyst and spermatocele?

A

You cannot clinically differentiate
Only way is to aspirate bc sperm present in fluid if spermatocele

154
Q

Ix Epididymal Cyst

A

Scrotal US
Transilumination - to eliminate hydrocele

155
Q

What is a Hydrocele?

A

Abnormal collection of fluid within tunica vaginalis
aka fluid surrounds testes

156
Q

Describe a 1º Hydrocele

A

More common and larger
Usually in young men
Assoc w/ patent processus vaginalis - which usually resolves in 1st year of life

157
Q

What can a 2º Hydrocele be secondary to?

A

Testis tumour
Trauma
Infection
TB
Testicular torsion
Generalised oedema

158
Q

Signs / Symptoms Hydrocele

A

Unless infected, shouldn’t be painful!

Non-tender, smooth, cystic swelling
Testis usually palpable but if large, might be difficult
Will transluminate

159
Q

DDx Hydrocele

A

Testicular torsion
Strangulated hernia

160
Q

Ix Hydrocele

A

Scrotal US

Serum AFP and HCG - exclude malignancy
FBC - to check for infection
Transillumination

161
Q

Tx Hydrocele

A

Resolve spontaneously
Esp in infancy - resolves by 2 years

Therapeutic aspiration or surgical removal

162
Q

What is a varicocele?

A

Abnormal dilation of testicular veins in pampiniform venomous plexus

163
Q

Pathophysiology Varicocele

A

Left renal vein invades L testicular vein
∴ compression
∴ impaired venous drainage (venous reflux)
∴ ↑ venous pressure
∴ vein dilation
∴ causes varicocele

164
Q

Signs / Symptoms Varicocele

A

Dull ache
Scrotal heaviness
“Bag of worms” - distended scrotal blood vessels

165
Q

Ix Varicocele

A

Venography
Colour doppler US - to see blood flow

166
Q

Tx Varicocele

A

Surgery !
If pain, infertility or testicular atrophy

167
Q

What is Haemotocele?

A

Blood in tunica vaginalis

168
Q

Cause Haemotocele

A

Trauma

169
Q

Tx Haematocele

A

Aspiration or surgery

170
Q

In testicular torsion, which cells are the most susceptible to ischaemia?

A

Germ cells

171
Q

What age is testicular torsion most common?

A

11-30 years

172
Q

What side is more commonly affected in testicular torsion?

A

Left

173
Q

Causes Testicular Torsion

A

Teens/Neonates :
Bell-clapper deformity
When testis isn’t fixed fully to scrotum ∴ can move freely on axis

Adults - testicular malignancy

174
Q

RF Testicular Torsion

A

FHx - Genetics

175
Q

Signs / Symptoms Testicular Torsion

A

Sudden onset testicular pain!
Makes walking difficult
Comes on during sports and physical activity

Inflamed & tender testicle
Abdo pain
N+V
Unilateral pain
High riding testicle
Absent cremasteric reflex
NEG Prehn’s sign

176
Q

DDx Testicular torsion

A

Epididymo-Orchitis
Tumour, trauma, acute hydrocele
Idiopathic scrotal oedema

177
Q

Ix Testicular Torsion

A

Emergency!!!!
QUICK!!
Don’t delay surgical exploration!

Doppler US - shows decreased blood flow!!
Urinalysis - to exclude infection and epididymis

178
Q

Tx Testicular Torsion

A

Surgery within 6 hours!!!!

Salvage rate = 90-100%
but if > 24 hours = 1-10% !

Orchidectomy and bilateral fixation

179
Q

What is a positive Prehn’s sign?

A

When lifting testicle lessens pain / provides relief

180
Q

When is Prehn’s sign POSITIVE?

A

Epididymitis
NEG IN TESTICULAR TORSION

181
Q

Typical case of Post-Streptococcus Glomerulonephritis

A

Child had a strep infection (pharyngitis, cellulitis, tonsilitis)
1-3 weeks later, they present with haematuria, oliguria, proteinuria etc

182
Q

Cause Post-Strep Glomerulonephritis

A

Lancefield Group A beta haemolytic streptococcus

e.g. STREP PYOGENS

183
Q

Pathophysiology Post-Strep Glomerulonephritis

A

Bacterial antigens are deposited in glomerulus
TYPE III HYPERSENSITIVITY REACTION

184
Q

Ix Post-Strep Glomerulonephritis

A

Urine dipstick and microscopy - RED CLAST CELLS
Proteinuria, ↓ GFR etc

Combined with history of previous Strep infection

185
Q

Cause IgA Nephropathy

A

Abnormal IgA1

186
Q

Pathophysiology IgA Nephropathy

A

Abnormal IgA is deposited in the mesangium
Kidney is then attacked by anti-glycan antibodies
∴ complement pathway is activated

Type III HYPERSENSITIVTY REACTION !!
(inflam occurs at site of deposition, not site of formation)

187
Q

Signs / Symptoms IgA Nephropathy

A

Usually in childhood, after a GI or resp infection

Nephritis Sx
+ Uraemia - anorexia, rash, lethargy etc

188
Q

How does Henloch-Schonlein Purpura present?

A

Similar to IgA Nephropathy
But also purpuric rash on legs, joint pain

189
Q

Ix IgA Nephropathy

A

History - to find cause
Measure eGFR, proteinuria, serum urea etc

GS!!! Biopsy!!!
Diffuse mesangial IgA deposits
Sub-endothelial and sub-epithelial deposits

Light microscopy - mesangial proliferation

Urine dipstick

190
Q

Tx IgA Nephropathy

A

Supportive !!
Control BP (ACEi, ARBs etc)
lower cholesterol
etc

Immunosuppression (to avoid immune complexes forming)
Induction = steroids + cyclophosphamide
Remission = steroids + azathioprine

191
Q

What is IgA Nephropathy also known as?

A

Berger disease

192
Q

What is Goodpasture’s Syndrome?

A

Autoimmune condition that attacks the type IV collagen in the basement membrane of lungs and kidney

193
Q

What type of hypersensitivity reaction is Goodpasture’s syndrome?

A

Type 2 - anti GBM antibodies

194
Q

Signs / Symptoms Goodpasture’s syndrome

A

HAEMOPTYSIS + HAEMATURIA
SOB + some resp signs !
Nephritic symptoms
Rapid progressive kidney failure

195
Q

Ix Goodpasture’s Syndrome

A

GS!! - anti-GBM and renal biopsy

196
Q

Tx Goodpasture’s syndrome

A

Plasma exchange - to remove antibodies
Steroids
Cyclophosphamide

197
Q

What is testicular appendage torsion?

A

NOT a medical emergency (unlike appendage torsion)
Twisting of the appendix of the testicle i think idk dont quote me on this look it up a bit more pls

198
Q

Types of Prostate Cancer

A

Adenocarcinomas - MC! arise from periph zone
Transitional cell carcinomas - arise from transitional zone
Small cell prostate cancer

199
Q

How can prostate cancer spread?

A

Local - to seminal vesicles, bladder, rectum
Via Lymph
Haematogenously - to bone, brain, liver, lung

CAN METASTASISE - to bone, lung, adjacent structures

200
Q

RF Prostate Cancer

A

Age
Obesity
FHx - BRCA1, BRCA2 (HOXB13 predisposition gene)
High fat, low fibre diet
↑ Testosterone
Black skin tone

201
Q

Screening Prostate Cancer

A

Prostate specific antigen
But not always reliable

202
Q

Signs / Symptoms Prostate Cancer

A

Asymptomatic at first

LUTS symptoms - same as BPH
FUUN SHIPP
Haematuria

Cancer B Sx - weight loss, anorexia, night sweats
Anaemia

Bone pain (metastases)

203
Q

Why is prostate cancer usually asymptomatic at first?

A

Bc most prostate malignancies arise from peripheral zone
Which is far from urethra
∴ can grow large before starts to present

204
Q

DDx Prostate cancer

A

BPH
Bladder cancer
Prostatitis

205
Q

Ix Prostate Cancer

A

DRE - hard, irregular
PSA - non specific
Trans-urethral US scan (TRUSS)

Prostate biopsy! - Gleason grading

Imaging
Bone Scan
TMN staging!

206
Q

Describe how one would use Gleason grading

A

Histological grades for 2 most common patterns (1-5)
Then add up together
Higher score = ↑ aggressive

Generally, 6 = low grade, 7 = mid grade
8 - 10 = high grade, v aggressive cancer

207
Q

Describe TNM staging for prostate cancer

A

T1 - no palpable tumour on DRE
T2 - palpable tumour but confined to prostate
T3 - palpable tumour that extends past prostate
(There is T3a and T3b, also T4 = metastases)

N stage - Nodes -> MRI scan, CT scan
M stage - Metastases -> bone scan

208
Q

Tx Prostate Cancer

A

If low risk, watchful waiting

Localised radical Tx = radical prostatectomy or radical radiotherapy

Hormone therapy - slows tumour growth
> GnRH agonist e.g. SC Goserelin, Leuprorelin
> Androgen receptor blockers e.g. Bicalutamide

If metastatic -
Bilateral surgical orchidectomy (castration) or palliative care :(

Treat hypercalcaemia with diuretics

Bisphophonates - zolendronic acid

209
Q

Why are hormone therapies esp used in prostate cancer?

A

Bc prostate malignancies are the malignancy most sensitive to hormone therapy

210
Q

How does Wilm’s tumour present?

A

IN CHILDREN
Abdo mass
Haematuria

211
Q

What is the major abdo malignancy in children?

A

Wilm’s tumour

212
Q

Wilm’s tumour is a malignancy of ?

A

Renal tubules
and mesenchymal cells

213
Q

When might PSA be raised?

A

BMI < 25
Black Africans
Taller men
Recent ejaculation
Recent rectal examination
Prostatitis
BPH
Prostate cancer
UTI

214
Q

Indications for dialysis

A

AEIOU

Acidosis - pH < 7.2 OR bicarbonate < 10mmol

Electrolyte imbalance - persistent hyperkalaemia 7mmol/L

Intoxication - BLAST (Barbiturates, Lithium, Alcohol, Salicylates, Theophylline)

Oedema (refractory pulmonary oedema)

Uraemia - encephalopathy or pericarditis, urea > 40

215
Q

Would the eGFR increase or decrease with Post-Strep glomerulonephritis? Why?

A

DECREASE
bc deposition of immune complexes ∴ ↓ ability to filter toxins
∴ ↓ eGFR

216
Q

What drugs should be stopped in AKI?

A

Stop the DAMN drugs

Diuretics & digoxin
ACEi / ARBs
Metformin
NSAIDs

217
Q

Big diff between IgA Nephropathy and Post-Strep

A

TIMELINE
Post-strep is 1-2 weeks later
IgA is days
i think?

218
Q

Quick!
Patho of NephrOtic syndrome?

A

Usually issue w filtration barrier - podocytes
∴ protein leaks into urine

219
Q

Causes Nephrotic Syndrome

A

MFM
Minimal change disease
Focal Segmental Glomerulosclerosis
*M**embranous Nephropathy

220
Q

General presentation of Nephrotic syndrome

A

PROTEINURIA > 3.5g/day
Hypoalbuminaemia
Oedema
Hyperlipidaemia

221
Q

General presentation of Nephritic syndrome

A

HAEMATURIA
↓GFR
Oliguria
Proteinuria < 2g/day
Oedema
HTN

222
Q

Pathophysiology Minimal Change disease

A

Cytokines attack foot processes of podocytes
∴ Shrinkage/Blunting of podocytes
∴ Protein leakage

223
Q

What Nephrotic syndrome is most common in children?

A

MINIMAL CHANGE DISEASE

224
Q

Ix Minimal Change Disease

A

Renal biopsy
Electron microscopy

225
Q

Tx Minimal Change Disease

A

Corticosteroids
+/- Cyclophosphamide or Cyclosporine (if freq recurring)

226
Q

Pathophysiology Focal Segmental Glomerulosclerosis

A

Podocytes are damaged (how?? no clue)
∴ proteins + lipids go into urine

Overtime, protein + lipids are trapped in glomerulus
∴ Hyalinosis (glassy appearance on histology)
∴ sclerosis

227
Q

RF Focal Segmental Glomerulosclerosis

A

African-American!!!

228
Q

2º Cause Focal Segmental Glomerulosclerosis

A

SCD
HIV
Heroin abuse
Kidney hypoperfusion

229
Q

Ix Focal Segmental Glomerulosclerosis

A

Renal biopsy & Histology - hyalinosis, effacement of foot processes & segmental sclerosis

Immunofluorescence - non-spec deposits of IgM and complement

230
Q

Tx Focal Segmental Glomerulosclerosis

A

Steroids

231
Q

Pathophysiology Membranous Glomerulonephritis

A

IgG deposition in sub-epithelial surgace
∴ thickening of glomerular capillary wall
∴ damaged glomerulus
∴ protein leaks out

232
Q

1º cause of Membranous Glomerulonephritis

A

PLA2R antigen targets glomerular podocyte membrane

233
Q

2º Membranous Glomerulonephritis

A

Autoimmune conditions
Viruses
Drugs
Tumours

234
Q

Ix Membranous Glomerulonephritis

A

Renal biopsy

Electron microscopy - thickened capillaries and GBM (spike and dome pattern!)
Effacement of foot processes

PLA2R antigen

235
Q

Tx Membranous Glomerulonephritis

A

Supportive - oedema, HTN, proteinuria etc

Immunosuppression - steroids, cyclophosphamide

RAAS blockade?

Anti-Coag

236
Q

Signs / Symptoms SLE Nephropathy

A

Rash
Arthralgia
Kidney failure
Pericarditis
Pneumonia

237
Q

Ix SLE Nephropathy

A

Anti-Nucelar antibody pos
Double stranded DNA pos

Low complement C3 + C4

238
Q

Tx SLE Nephropathy

A

Immunosuppresion -
Steroids
Cyclophosphamide
Rituximab

Phase 2 Quick (17 decks)

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