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Clinical Flashcards

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1
Q

What is the presentation of a UTI?

A

Dysuria
Frequency
Smell

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2
Q

Who are likely to get UTIs?

A 
Very young (unwell, failure to thrive)
Very old (incontinence, off their feet)
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3
Q

What prevents UTIs?

A
  • Free flow of urine
  • Low pH
  • High osmolarity
  • High ammonia
  • Prostatic secretions are bacteriostatic
  • Anti-bacterial antibodies
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4
Q

What part of the urinary tract is not sterile?

A

Terminal urethra

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5
Q

What is a problem of a urinated specimen?

A

Always contaminated by terminal urethral flora

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6
Q

What type of specimen diminishes infecting urine with urethral flora bacteria?

A

Mid-stream specimen of urine (MSSU)

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7
Q

Will a MSSU have no bacteria contamination?

A

No, always grow on culture.

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8
Q

How can you tell contamination from real infection in a MSSU?

A

MSSU culture 10^5 usually = infection

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9
Q

What measurement of MSSU culture suggests potential infection if symptoms exist?

A

10^3 -> 10^4

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10
Q

If MSSU culture = 10^3 –> 10^4, what is the % chance of no infection?

A

50%

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11
Q

If MSSU is <10^3, what does this suggest?

A

No infection

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12
Q

When is it difficult to collect an MSSU?

A

Young children

Elderly

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13
Q

What is the most common bacteria seen in UTIs?

A

E.coli

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14
Q

What is the most common route of infection in UTIs?

A

Ascending

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15
Q

Where does an infection of the kidneys usually come from?

A

Ascending from bladder

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16
Q

What type of UTI is most serious?

A

Upper

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17
Q

What infections lead to inflammatory responses?

A

Urethritis
Cystitis
Ureteritis
Acute Pyelonephritis

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18
Q

What is cystitis?

A

Infection of bladder

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19
Q

What is acute pyelonephritis?

A

Kidney infection

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20
Q

What is chronic pyelonephritis?

A

Recurrent/prolonged kidney infection

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21
Q

What are predisposing factors to UTI?

A
  1. Stasis of urine
  2. Pushing bacteria up urethra
  3. Generalised predisposition to infection
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22
Q

What causes stasis of urine?

A
  1. Obstruction

2. Spinal cord/brain injuries

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23
Q

What causes bacteria to be pushed up urethra?

A
  1. Sexual activity in females

2. Catheterisation

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24
Q

Give two examples that cause predisposition to infection?

A

Diabetes (glucose in urine)

Chemotherapy (poor function of WBC)

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25
What happens when there is obstruction at level of urethra?
Dilation of upper urethral and bladder dilatation --> bilateral hydroureter --> bilateral hydronephrosis --> chronic renal failure
26
What is hydronephrosis?
Water in kidney
27
What happens when there is obstruction at the level of the renal pelvis on 1 side?
Unilateral hydroureter --> dilatation of pelvis --> unilateral hydronephrosis
28
What are the consequences of obstruction?
Proximal dilatation -> Slowed urine flow -> Sedements form -> Stone form Obstruction
29
What is the triad of consequences of obstruction?
Infection Calculi Obstruction
30
What should you do with obstruction in children?
Always investigate at 1st presentation --> send to paediatric surgeons
31
What is vesicoureteric reflux?
Decreased angulation at insertion of ureter in bladder --> can cause hydroureter
32
What is important to consider as a cause of UTI in children?
Vesicoureteric reflux
33
What are common causes of obstruction in adults?
- Tumours - Calculi - Men: benign prostatic hyperplasia - Women: uterine prolapse
34
Why does spinal cord/brain injury increase risk of UTI?
Decreased sensation --> no sense of when to micturate and don't empty bladder completely leaving urine in bladder (stasis)
35
At what age do males have an increased risk of UTIs?
>50 years
36
Why do females have a predisposing risk of UTI?
- Short urethra - Lack of prostatic bacteriostatic secretion - Closeness of urethral orifice to rectum - Sexual activity - Pregnancy (pressure on ureters and bladder)
37
Name acute complications of UTI.
Severe sepsis and septic shock
38
Name chronic complications of UTIs.
1. Chronic pyelonephritis --> hypertension --> chronic renal failure 2. Calculi --> obstruction --> hydronephrosis --> hypertension --> chronic renal failure
39
What is the key question for UTI?
Why has the patient presented now?
40
What is glomerulonephritis?
Disease of glomerulus (inflammatory or non-inflammatory)
41
What is the difference between primary and secondary glomerulonephritis?
Primary = glomerulus affected only Secondary = other parts of body affected e.g SLE
42
What is the aetiology of glomerulonephritis?
With or without immunoglobulin deposition
43
What are the common presentations of glomerulonephritis?
Haematuria Heavy proteinuria Slowly increasing proteinuria Acute renal failure
44
What are the main causes of haematuria?
UTI Urinary tract stone Urinary tract tumour Glomerulonephritis
45
What does IgA do to glomerulus in IgA glomerulonephritis?
IgA deposited --> stuck within mesangium --> irritates mesangial cells and causes them to proliferate (more matrix produced)
46
What does IgG do to glomerulus in membranous glomerulonephritis?
IgG stuck to membrane --> deposits between basal lamina and podocytes cannot go further and not filtered into urine --> activates compliment --> punches holes in filter --> albumin now filtered
47
Name 4 types of glomerulonephritis.
- IgA glomerulonephritis - Membranous glomerulonephritis - Diabetic nephropathy - Crescentic (Wegner's) glomerulonephritis
48
When are Kimmelsteil Wilson lesions found?
Diabetic nephropathy
49
What is the most sever glomerulonephritis?
Crescentic glomeulonephritis
50
What does crescentic glomerulonephritis do to the glomerulus?
Crushes glomerulus from cell proliferation and influx of macrophages around glomerular tuft
51
What is granulomatosis with poilyangitis?
Form of vasculitis that affects vessels in kidneys, nose and lungs
52
What test can be done for crescentic (Wegner's) glomerulonephritis?
ANCA (Anti-neutrophil cytoplasmic antibodies)
53
What is given to treat Wegner's granulomatosis (75% complete remission rate)?
Cyclophosphamide
54
What are the structures of the upper urinary tract?
Kidneys | Ureters
55
What are the structures of the lower urinary tract?
Bladder | Bladder outflow tract
56
What makes up the bladder outflow tract?
``` Internal urethral sphincter Prostate External urethral sphincter Urethra Urethral meatus Foreskin ```
57
What are the structures of the kidneys?
Parenchyma | Pelvic-calyceal system
58
What are the structures of the ureters?
Pelvic-ureteric junction Ureter Vesicle-ureteric junction
59
Why is it important to understand that the foreskin is part of the bladder outflow tract?
Phimosis
60
Give an example fo renal disease caused by infection?
Pyelonephritis
61
What drugs can cause nephrotoxicity?
Antibiotics e.g gentamicin | NSAIDs
62
Why are NSAIDs nephrotoxic to those with poor renal reserve?
NSAIDs reduce prostaglandins causing vasoconstriction
63
Give an example of renal disease caused by inflammation?
Glomerulonephritis
64
Give an example fo renal disease which is hereditary?
Polycystic kidney disease
65
How does renal disease present?
``` Pain Pyrexia Haematuria Proteinurea Pyuria Mass on palpation Renal failure ```
66
What is the definition of proteinuria?
Urinary protein excretion >150mg/day
67
How many types of haematuria are there?
Three: Microscopic Dipstick Macroscopic
68
What is the definition of microscopic haematuria?
3 or more red blood cells per high power field
69
Define oliguria.
Urine output <0.5ml/kg/hr
70
Define absolute anuria
No urine output
71
Define relative anuria.
<100ml/24 hr
72
Define nocturia.
Waking up at night once or more than once to micturate
73
Define nocturnal polyuria.
Nocturnal urine output >1/3 of total urine output in 24 hours
74
How do you distinguish between nocturia and nocturnal polyuria?
Frequency volume chart/bladder diary
75
How do you classify AKI?
``` RIFLE Risk Injury Failure Loss End-stage kidney disease ```
76
Give an example of ureteric disease caused by infection.
Ureteritis
77
Give an example of ureteric disease with iatrogenic cause.
Inadvertently cut or tied during hysterectomy or colon resection
78
Give an example of ureteric disease with hereditary cause .
PUJ obstruction | VUJ reflux
79
Where can obstruction occur in the ureters?
Intra-luminal Intra-mural Extra-luminal
80
What can cause obstruction of ureters?
``` Stone Blood clot Scar tissue TCC Pelvic mass Lymph nodes ```
81
How does ureteric disease present?
``` Pain Pyrexia Haematuria Palpable mass Renal failure ```
82
How does bladder disease present?
``` Pain Pyrexia Haematuria LUTS Recurrent UTIs Chronic urinary retention Urinary leak from the vagina Pneumaturia ```
83
What are two types of LUTS?
Storage | Voiding
84
What can cause pneumaturia?
Colo-vesical fistula
85
What can cause a coli-vesical fistula?
Diverticulosis | Bladder tumour
86
What is the risk of bladder cancer in patient who presents with frank haematuria?
25%-30%
87
What is the risk of renal cancer in patient who presents with frank haematuria?
0.5%-1%
88
What is the most likely cause of unexplained haematuria?
Bladder cancer
89
What are causes of Lower Urinary Tract Symptoms?
``` Bladder pathology Bladder outflow obstruction Pelvic floor dysfunction Neurological causes Systemic disorders ```
90
How do bladder outflow tract diseases present?
``` Pain Pyrexia Haematuria LUTS Recurrent UTIs Acute urinary retention Chronic urinary retention ```
91
How is acute urinary retention defined?
Painful inability to void with a palpable and permissible bladder
92
How is chronic urinary retention defined?
Painless, palpable and permissible bladder voiding
93
What type of urinary retention has high residual after voiding?
Chronic urinary retention
94
What type of urinary retention is most likely to cause renal failure?
Chronic (if high pressure urinary retention)
95
How are urinary tract infections diagnosed?
Microbiological evidence AND symptoms/signs
96
What microbiological evidence is required to diagnose UTI?
10^4 cfg/ml from MSSU specimen with no more than two species of micro-organisms
97
What are the two types of UTI?
Uncomplicated (e.g young sexually active females) | Complicated (everyone else)
98
What are complications of UTI?
``` Infective: sepsis Renal failure Bladder malignancy Acute urinary retention Frank haematuria Bladder or renal stones ```
99
What are emergencies related to UT diseases?
``` Acute renal failure Sepsis Renal colic Severe haematuria causing haemorrhage stroke Testicular torsion Paraphimosis Priapism Chronic high-pressure urinary retention Acute urinary retention ```
100
What organisms are commonly associated with UTIs?
E.coli, Klebsiella, proteus, pseudomonas
101
What are the key aspects measured to assess for kidney disease?
Filtration (excretion) function Filtration (barrier) function Anatomy - abnormality
102
In a clinical setting, what is used to measure excretory renal function?
GFR estimating equations
103
What factors influence serum creatinine and GFR?
``` Age Ethnicity Gender Weight Liver disease etc ```
104
Where does creatinine come form?
Muscle breakdown and meat ingestion
105
What factors are used in formulae to estimate GFR from serum creatinine?
``` Age Weight SCr Gender Ethnicity ```
106
What classification system is used for CKD?
International CKD Classification System
107
How many stages are there in the international CKD Classification System?
1,2,3a,3b,4,5
108
What is the eGFR for moderately impaired CKD (stage 3a and 3b)?
45-49 | 30-44
109
What is normal eGFR?
>90
110
What eGFR is seen in advanced CKD or on Dialysis?
<15
111
How do we asses kidney filtering function?
1. Urinalysis ("dipstick") | 2. Protein quantification (protein creatinine ratio)
112
What is the definition for CKD?
Chronic CKD - presence of kidney damage (abnormal blood, urine or x-ray findings) or GFR<60ml/min/1.73m^2 that is present for 3 or more months
113
What population is CKD commonly present in?
The elderly
114
What is the the aetiology of CKD?
``` Diabetes Glomerulonephritis Hypertension Renovascular disease Polycystic kidney disease ```
115
What are the symptoms of CKD?
``` Hypertension SOB Pallor Cognitive changes Change in urine output Haematuria Proteinuria Peipheral oedema Itch and cramps Anorexia Vomiting Taste disturbance ```
116
What imaging modality is used to diagnose CKD?
Ultrasound
117
What pathological test is carried out to detect aetiology of CKD?
Kidney biopsy
118
What is the most important consideration in CKD?
BP control
119
How do you control the rate of renal decline?
Control BP and proteinuria
120
How do you control proteinuria?
ACEi or ARBs
121
What is proteinuria a sign of?
End stage organ damage with high blood pressure
122
What complications are related to reduced eGFR?
``` Acidosis Anaemia Bone disease CV risk Death and dialysis Electrolytes Fluid overload Gout Hypertension ```
123
What do specialist renal dieticians look at in in patients with CKD?
Fluid, phosphate and potassium intake
124
What is worse proteinuria associated with?
Worse outcomes
125
What are the features of glomerulonephritis?
Haematuria Proteinuria Hypertension Renal insufficiency
126
What can be the source of haematuria?
``` Kidney Ureter Bladder Prostate Urethra ```
127
What are the two types of proteinuria?
Glomerular or tubular
128
What is nephritic state?
Active urine sediment (haematuria, dysmorphic RBCs, cellular casts) Hypertension Renal impairment
129
What is seen in nephrotic syndrome?
Oedema
130
What causes nephrotic syndrome?
Primary (idiopathic) glomerular disease or secondary glomerular diseases
131
What are differential diagnoses for nephrotic syndrome?
Congestive HF | Hepatic disease
132
What is the spectrum of glomerulonephritis?
Urinary sediment abnormality Proteinuria Nephrotic syndrome Nephritic state
133
What tests are used for kidney biopsy?
H&E Immunofluoresce Electron microscopy
134
What is the commonest cause of glomerulonephritis?
IgA nephropathy
135
What is the presentation of IgA nephropathy?
Microscopic haematuria (+/- proteinuria) Nephrotic syndrome IgA crescent glomerulonephritis
136
What is uraemia?
Urea in the blood
137
How does uraemia present?
``` Nausea Vomiting Fatigue Weight loss Muscle cramps Pruritis Mental state changes Visual disturbances Increased thirst ```
138
When does uraemia occur?
When creatinine clearance is below 10-20ml/min
139
What are the signs of nephrotic syndrome?
``` Proteinuria Hypoalbuminaemia Oedema Hyperlipidaemia Frothy urine ```
140
What are the signs of nephritic syndrome?
Haematuria Proteinuria Hypertension Low urine output <300ml/day
141
What is the pathogenesis of nephritic syndrome?
Inflammation
142
What is the pathogenesis of nephrotic syndrome?
Gaps in podocytes
143
Name 3 types of glomerulonephritis that present with nephrotic syndrome.
Membranous Minimal change Focal and segmental
144
Name 3 types of glomerulonephritis that present with nephritic syndrome.
Post-infective IgA nephropathy Crescentic
145
What type of glomerulonephritis is post-infective GN?
Proliferative
146
Is IgA nephropathy proliferative or non-proliferative?
Proliferative
147
Is Membranous GN proliferative or non-proliferative?
Non-proliferative
148
Is minimal change GN proliferative or non-proliferative?
Non-proliferative
149
Describe proliferative GN.
Excess cells in glomerulus
150
Describe non-proliferative GN.
Normal cells, glomeruli look normal or scarred
151
What is the aetiology of nephrotic syndrome?
GASH'D: ``` GN Alport's syndrome SLE HSP ' DM/Drugs ```
152
What is the aetiology of nephritic syndrome?
PAIRS ``` Post-strep Alport's syndrome IgA nephropathy Rapidly progressing (crescentic) SLE ```
153
What investigations should be carried out for Nephrotic syndrome?
Bloods Urinalysis (dipstick, culture) USS Renal biopsy
154
What investigations should be carried out for Nephritic syndrome?
Bloods Urinalysis (dipstick, culture) USS Renal biopsy
155
What is the management for nephrotic syndrome?
``` WASPS: Warfarin or heparin ACEi or ARB Salt and fluid restrictions Pneumococcal vaccine Statins ```
156
What is the management for nephritic syndrome?
``` Monitor: fluid balance, BP, renal function, weight Restrict Na, K and fluid Treat hypertension Consider prophylactic penicillin Consider dialysis and immunosuppression ```
157
Who is most likely to get IgA nephropathy?
Males in 20s/30s
158
What is the most common cause of post-infective GN?
Strep pyogenes
159
What GN is most common in children?
Minimal change GN
160
What is the aetiology for Crescentic GN?
``` ANCA associated Anti-GBM/Goodpasture's IgA vasculitis SLE Post-infective GBN Granulomatosis with polyangiitis Idiopathic ```
161
What is the commonest cause of nephrotic syndrome in adults?
Membranous GN
162
What is the main test to diagnose nephrotic syndrome?
Renal biopsy
163
Does nephrotic or nephritic syndrome have a higher chance of progressing to CKD?
Nephrotic
164
What is the treatment regime for minimal change GN and focal and segmental GN?
WASPS + Corticosteroids (Prednisolone)
165
Does nephritic or nephrotic syndrome require steroids for treatment?
Nephrotic
166
What are transplant surgical complications?
Vascular (bleeding, thrombosis, lymphocele) Ureteric Infections
167
Name 3 immunosuppressive agents.
Corticosteroids Calcineurin inhibitors Anti-proliferatives (azathioprine)
168
What are tacrolimus and cyclosporin?
Calcineurin inhibitors
169
What are side effects of corticosteroids?
Hypertension Hyperglycaemia Infections Bone loss
170
What are side-effects of tacrolimus?
Hyperglycaemia AKI Tremor
171
What are side-effects of cyclosporin?
Hirsutism Hypertension AKI Gout
172
What is a common immunosuppression protocol?
1. Induction: Basiliximab | 2. Maintenance: Tacrolimus + Mycophenolate + steroids
173
What are the different types of kidney donors?
- Deceased (after brain death or cardiac death) | - Living (related donor, living unrelated)
174
What are the different types of living donors?
Spousal Altruistic Paired/pooled
175
What is the standard criteria for renal transplant?
< 60 years
176
What is the extended criteria for renal transplant?
>60 years | Aged 50-59 + h/o high BP, death from cerebrovascular accident or terminal creatinine of >132
177
What is the follow-up time after transplant?
12 years
178
What are complications of renal transplantation?
Rejection Infection Cardiovascular Malignancy
179
What are the types of rejection in renal transplant?
Cell mediated | Humoral
180
What are cardiovascular complications of renal transplant?
CRF Hypertension Hyperlipidaemia PT diabetes
181
What are the types of acute rejection?
Hyperacute | Acute
182
Histologically, what suggests T cell mediated rejection?
Lymphocyte infiltrate Tubulitis Endarteritis Endothelialitis
183
Histologically, what suggests antibody mediated rejection?
Microvascular inflammation Donor specific antibodies Positive C4d in peritubular capillaries
184
What immunosuppressive drug is diabetogenic?
Tacrolimus
185
What is the most common transplant-related infection?
Cytomegalovirus
186
How does CMV present?
``` Viremia Tissue invasion (pneumonitis, retinitis, hepatitis etc) ```
187
In addition to CMV, name two other viruses common in immunosuppression?
BK virus | JC virus
188
What are clinical manifestations of BK virus after renal transplantation?
Ureteral stenosis Interstitial nephritis ESRF
189
What are risk factors for BKAN?
- Intensity of immunosuppression - Older age, male, white, DM - Graft injury, HLA mismatch
190
What is the treatment for BKAN?
Reduce immunosuppression | Antiviral therapy
191
How many stages are in acute kidney injury?
3
192
How is AKI defined?
1. Increase in serum creatinine by > 26.5umol/l within 48 hours OR >1.5x baseline 2. Urine vol <0.5ml/kg/h for 6 hours
193
What are immediately dangerous consequences of AKI?
``` Acidosis Electrolyte imbalance Intoxication toxins Overload Uraemic complications ```
194
What are the main categories of causes of AKI?
Pre-renal, renal/intrinsic, post-renal
195
Give examples of post-renal AKI causes
Kidney stones Tumours Prostatic hypertrophy
196
Give examples of renal/intrinsic AKI causes.
GN, Vasculitis, myeloma, radiocontrast, rhabdomyolysis, drugs e.g NSAIDs
197
Give examples of pre-renal AKI causes.
Sepsis, hypovolaemia, cardiac failure, hypotension, V&D
198
If a patient is at risk of AKI what should be activated?
STOP AKI Prevention Care Bundle
199
What does STOP stand for in the STOP AKI prevention care bundle?
Sepsis Toxins Optimise BP and volume Prevent harm (daily U&Es, fluid balance)
200
What investigations should be carried out for AKI?
``` History Assess volume status Drugs Insults Renal function Urine dipstick FBC, U&Es, clotting Biopsy USS Blood gas ```
201
What are uraemic complications indicative for dialysis?
``` Pericardial rub (pericarditis) Encephalopathy ```
202
When should RRP in AKI be considered?
``` Acidosis Electrolyte imbalance Intoxication - TOXINS Overload Uraemic complications ```
203
How do you treat hyperkalaemia?
1. 10ml of 10% Calcium gluconate over two mins 2. Salbutamol, Insulin-dextrose 3. Diuresis, dialysis, anion exchange resins
204
What should be carried out for cloudy urine?
Dipstick
205
What is a MSU?
Mid-stream urine (after first 10-20ml)
206
What does dipstick analysis look at?
Nitrate Protein Leukocytes
207
If only leukocytes are positive on dipstick, what should you do?
Send for culture
208
What does recurrent UTI in men suggest?
Prostatitis
209
Why is follow-up after UTI in children important?
Vesicle-ureteric reflux
210
Who is most likely to get acute pyelonephritis?
Women of child-bearing age
211
What are two characteristic features of acute pyelonephritis?
Loin pain | Fever
212
What tests should be done for acute pyelonephritis?
Blood cultures | Urine cultures
213
What should you do for a catheter-related UTI?
Remove catheter immediately
214
When should asymptomatic bacteriuria be screened for?
Pregnancy
215
What is sterile pyuria?
Undeclared presence of pus cells in urine
216
What are signs and symptoms of chronic pyelonephritis?
Vague abdo discomfort Hypertension Pyuria
217
What are histological signs of chronic pyelonephritis?
Chronic interstitial nephritis
218
Why are females more likely to get a UTI?
Short urethra close to rectum, trauma during childbirth, stasis of urine during pregnancy
219
Name 3 predisposing factors for UTI excluding female gender.
Anatomical abnormalities Stones Instrumentation
220
What organism most commonly causes UTI?
E.coli
221
In addition to MSU, what other methods of urine collection are there?
Catheter specimens Clear catch sampling (paeds) Collection pads Suprapubic aspiration
222
What is the mechanism of E.coli in causing UTIs?
P fimbriae adhere to uroepithelium
223
What type of commensal causing UTI, produces urease (convert urea to ammonia --> alkalinity, stones)
Proteus
224
What is a coagulase negative commensal which is common in sexually active women?
Staph. Saprophyticus
225
Name three microorganisms that commonly cause UTI from catheters and are more Abx resistant?
Klebsiella Proteus Pseudomonas
226
What do mixed cultures usually represent?
Contamination
227
How do you treat a suspected lower UTI in women?
3 days of trimethoprim or ciprofloxacin
228
If there is no response to 3 days of antibiotics in a woman with suspected lower UTI, what should you do?
Send for cultures
229
How do you treat a suspected lower UTI in a man?
14 days ciprofloxacin
230
What treatment is given for a suspected UTI in pregnancy?
Nitrofurantoin if not term or Cephalexin
231
When should treatment be given for asymptomatic bacteraemia?
Pregnancy or pre-op
232
What is used to describe the pathology of the prostate gland?
McNeal's prostatic zone.
233
Discuss the Hard Diagram.
LUTS, BOO and BPE can co-exist and exist independently
234
What zone of the prostate is likely to be affected by benign prostatic hyperplasia?
Transition zone
235
What can benign prostatic hyperplasia result in?
BOO
236
What are the two types of LUTS?
Obstructive vs Irritative
237
What is used to score LUTS and prostate symptoms?
IPSS (International Prostate Scoring System)
238
What is used to assess LUTS?
IPSS | Frequency volume chart
239
What are the signs of a storage (irritative) LUTS?
Frequency Nocturia Urgency +/- urge incontinence
240
What are the signs of a voiding (obstructive) LUTS?
Hesitency Poor stream Terminal dribbling Incomplete emptying
241
What physical examinations should be carried out for prostatic symptoms?
Abdomen Penis DRE Urinalysis
242
Why should you check anal tone?
Some urological conditions can be neurological conditions
243
What physical investigations should be carried out for prostatic symptoms?
- MSSU - Flow rate study - Post-void bladder residual - - USS - Bloods: PSA, Urea and creatinine - Renal tract USS - Urodynamic studies
244
If PSA is raised or abnormal, what test should be carried out?
TRUS-guided prostate biopsy
245
When should you carry out cystoscopy?
When haematuria
246
How do you treat uncomplicated BPO?
- Watchful waiting - a-blockers +/or 5 a-reductase inhibitors - Surgery: TURP, open retropubic or transvesical prostatectomy
247
What is the medical treatment options for BPO?
a-blockers +/or 5 a-reductase inhibitors
248
What is the main treatment of LUTS due to BPO?
Alpha blockers
249
What are the surgical options fro uncomplicated
- TURP - Open retropubic or transvesical prostatectomy - Endoscopic ablative procedures
250
What are the main side-effects of a-blockers?
Hypotension | Retrograde ejaculation
251
Name two a-blockers used for LUTS due to BPO?
Tamsulosin | Alfuzosin
252
Name two 5a-reductase inhibitors?
Finasteride | Dutasteride
253
What is a problem with 5a-reductase inhibitors?
Interfere with testosterone metabolism (impaired sexual function and breast growth)
254
How does 5a-reductase inhibitors work?
Stromal part of prostate driven by by-product of testosterone (dihydrotestosterone). This area is blocked by these drugs i.e they shrink prostate gland.
255
What are complications of TURP?
``` Bleeding Infection Retrograde ejaculation Stress urinary incontinence Prostatic regrowth causing recurrent haematuria or BOO ```
256
What is the gold standard surgical intervention for uncomplicated BPO?
Transurethral resection of prostate (TURP)
257
What are complications of BOO?
``` Progression of LUTS Acute urinary retention Chronic urinary retention Urinary incontinence UTI Bladder stone Renal failure ```
258
What is the treatment for complicated BOO?
Medical therapy rarely works. | Surgery ultimately necessary
259
If complicated BOO and unsuitable for surgery, what is the management?
- Long-term catheter (urethral or suprapubic) | - clean intermittent self-catheterisation
260
What are the two types of urinary tract obstruction?
Upper | Lower
261
What are common sites of upper urinary tract obstruction?
PUJ Ureter VUJ
262
What are intrinsic causes of urinary tract obstruction?
``` Stones Ureteric tumour (TCC) Blood clot Fungal ball Scar tissue ```
263
What are extrinsic causes of urinary tract obstruction?
- Lymph nodes (tumour) - Abdominal mass - Iatrogenic - Abdo/pelvic mass - Cervical tumour - Prostate cancer
264
What are the signs/symptoms of Upper Urinary Tract Obstruction?
``` Pain Frank haematuria Palpable mass Microscopic haematuria Signs of complications ```
265
What are complications of urinary tract obstruction?
Infection and sepsis | Renal failure
266
What are signs of acute obstruction?
Pain
267
High pressure in kidneys causes chronic obstruction by what mechanism?
Disturbs countercurrent mechanism
268
What is the management of an acute upper urinary tract obstruction?
- Resuscitation | - Emergency treatment of obstruction (percutaneous nephrostomy insertion or retrograde send insertion)
269
Describe a nephrostomy.
- Percutaneous puncture, usually under LA + sedation --> obstruction relieved - USS guided
270
What is the a ureteric stent?
Silicone wire up ureter and into kidney, x-ray guided, kidney dilates and urine passes down and around tube
271
When should a nephrostomy not be carried out?
If suspected TCC
272
What are signs of lower urinary tract obstruction?
- LUTS - Acute urinary retention - Chronic urinary retention - Recurrent UTI and sepsis - Bladder stones - Renal failure - Frank haematuria
273
What should you do to manage chronic retention?
Immediately catheterise (14/16F)
274
What is the difference between high and low pressure chronic retention?
High = painless, incontinent, raised Cr, Bilateral hydronephrosis Low = painless, dry, normal Cr, normal kidneys
275
What is more dangerous, high or low pressure chronic retention?
High pressure
276
What are complications of chronic retention?
Decompression haematuria | Post-obstructive diuresis
277
What is uraemia?
Excess urea and nitrogen based waste products in blood
278
How does uraemia present?
- Begins with malaise and fatigue - Also sickness, vomiting and death if not treated - Can involve almost any organ
279
In a patient with ESRD, at what eGFR should RRT be given?
<10ml/min
280
What are types of RRT?
Renal transplant Haemodialysis Peritoneal dialysis Conservative kidney management
281
Define dialysis.
Solute concentration of solution a is altered by exposing to a second solution (B) through a semipermeable membrane
282
What are the two principles of dialysis?
Diffusion | Ultrafiltration
283
What are the pre-requisites for dialysis?
- Semi-permeable membrane - Adequate blood exposure - Dialysis access - Anticoagulation in HD
284
What are types of vascular access in HD?
AV fistula AV prosthetic graft Tunnelled venous catheter Temporary venous catheter
285
What restrictions are put in place for dialysis patients?
Fluid | Diet (limit K+, Na+, PO4-)
286
Name the three types of peritoneal dialysis.
CAPD (continuous ambulatory) APD (automated - at night) Hybrid
287
How does PD work?
Balanced solution (electrolytes, GLc) instilled into peritoneal cavity then after dwell time, fluid drained and fresh dialyse instilled
288
What are complications of pD?
Exit site infection PD peritonitis Ultrafiltration failure Encapsulating. peritoneal sclerosis
289
Name 4 indications for dialysis in ESRD.
1. Advanced uraemia (GFR 5-10ml/min) 2. Severe acidosis ( Bicarb <10mmol/l) 3. Resistant increase in K+ (<6.5mmol/l) 4. Resistant fluid overload
290
What is fluid restricted to in HD patients?
500-800ml/24 hours
291
What other drugs are given to dialysis patients?
1. Iv iron supplements and erythropoietin injections for anaemia 2. Activated vit D, phosphate binders for renal bone disease 3. Heparin 4. Water soluble vitamins 5. Antihypertensives
292
Name 3 complications of HD.
CV problems Coagulation problems Others e.g allergy
293
Name 3 complications of PD.
Infection Mechanical Ultrafiltration problems
294
Who decided which dialysis modality?
Patient and MDT
295
What are urothelial cancers?
Involve epithelium of urinary tract (bladder and upper tract)
296
Where is the most common site of urothelial cancer?
Bladder
297
What is the most common tumour type of bladder cancer?
Transitional cell carcinoma
298
When is squamous cell carcinoma of the bladder common?
Endemic schistosomiasis regions
299
What are the risk factors of TCC of the bladder?
Smoking Aromatic amines Non-hereditary genetic abnormalties
300
What are the risk factors of SCC of the bladder?
Schistosomiasis Chronic cystitis Cyclophosphamide therapy Pelvic radiotherapy
301
What is the rarest type of bladder cancer?
Adenocarcinoma (1%)
302
What are the presenting symptoms of bladder cancer?
- Painless visible haematuria (frank or microscopic) - Invasive or metastatic symptoms - recurrent UTI - storage symptoms: dysuria, frequency, nocturia, urgency +/- urge incontinence, bladder pain
303
What should you suspect if storage bladder symptoms?
Carcinoma in situ
304
How do you investigate haematuria?
- Urine culture - Dipstick - Cystourethroscopy - Upper tract imaging - Urine cytology - BP - U&Es
305
How do you investigate frank haematuria?
- Flexible cystourethroscopy within 2 weeks - IVU and USS - CT Urogram
306
How is urothelial tumours diagnosed?
- Cystoscopy and endoscopic resection (TURBT) | - EUA to assess bladder mass before/after TURBT
307
How is urothelial tumours staged?
CT and CTU | Bone scan if symptomatic
308
How is urothelial tumours treated?
Endoscopic or radical
309
How are bladder tumours classified?
Grade of tumour | Stage of tumour (TNM, T stage - superficial or muscle invasive)
310
What is the exception of normal classification of bladder tumours?
Carcinoma in situ
311
What is a precursor of muscle invasive bladder cancer?
Carcinoma in situ
312
What is the treatment for low-grade non-muscle invasive bladder cancer?
endoscopic resection + chemo
313
What is the treatment for high-grade non-muscle invasive or CIS bladder cancer?
Endoscopic resection, intravesical BCG
314
What is the treatment for muscle invasive bladder cancer?
neoadjuvant chemo | Radical radiotherapy and/or radical cystoprostatectomy or radical surgery
315
What is the prognosis of non-invasive, low-grade bladder cancer?
90% 5 years
316
What is the prognosis of invasive, high-grade bladder cancer?
50% 5 years
317
What are the presenting symptoms of UTUC?
- Frank haematuria - Unilateral ureteric obstruction - Flank or loin pain - Symptoms of nodal or metastatic disease
318
How is UTUC diagnosed?
- CT-IVU - Urine cytology - Ureteroscopy and biopsy
319
How are upper tract TCCs treated?
Nephro-ureterectomy
320
If UTUC and unsuitable for Nephro-ureterectomy, what is the management?
Nephron-sparing endoscopic treatment
321
Name two benign renal cell carcinomas.
Oncocytoma | Angiomyolipoma
322
Name the most common malignant renal cancer.
Renal adenocarcinoma
323
Where do most renal adenocarcinomas arise?
Proximal tubules
324
What are the risk factors for adenocarcinoma?
- FH - Smoking - Anti-hypertensive medications - Obesity - ESRF - Acquired renal cystic disease
325
How does renal adenocarcinoma present?
- 50% asymptomatic - Classic triad: flank pain, mass, haematuria - Paraneoplastic syndrome - metastatic disease
326
Describe the staging of renal cancer.
T1: <7cm confined in renal capsule T2: >7cm confined in capsule T3 (A,B,C): local extension outside capsule T4: Invades beyond gerona's fascia
327
How does renal cancer spread?
- Direct through capsule - Venous through renal vena and IVC - Haeamatogenous to lungs and bones - Lymphatic
328
How is renal adenocarcinoma investigated?
- CT - Bloods: U&Es, FBC - Others: USS, DMSA or MAG3 renogram
329
What is the function of DMSA or MAG3 renogram?
Assess split renal function if doubts about contralateral kidney
330
How is renal adenocarcinoma managed?
- Laparoscopic radical nephrectomy (curative if T1 or T2) | - palliative cytoreductive nephrectomy if palliative metastatic disease
331
What medical treatment is prescribed in renal adenocarcinoma?
- Multitargeted receptor tyrosine kinase inhibitors | - Immunotherapy
332
What is the prognosis of T1 Renal cancer?
95% 5 years
333
What is the prognosis of T4 renal cancer?
20% 5 years
334
What are indications for renal imaging?
- Renal colic and renal stone disease - Haematuria - Suspected renal mass - UTIs - Hypertension
335
Name 4 imaging techniques used in renal imaging.
- Plain film - Contrast studies (IVU, pyelography, cystography) - USS +/- contrast - CT and CTU
336
What contrast studies are used in renal imaging?
- IVU - Pyelography - Cystography
337
What does pyelography involve?
Injection of contrast into ureters
338
In what patients are micturating cystourethrography commonly used in?
Paediatrics --> vesicle-ureteric reflux and its grade
339
Why is US useful in renal patients?
Contrast is not nephrotoxic
340
What are the disadvantages of US in renal patients?
Poor visualisation of ureters
341
What is the current image modality of choice for detection of renal stones, staging and investigation of haematuria?
CT
342
When is CT of kidneys indicated?
- Detection of renal stones - Staging - Investigation of haematuria
343
What is the risk of CT with contrast of kidneys?
Nephrotoxicity
344
What is an advantage of MRI of the kidneys?
Imaging of urothelium without contrast (MRU)
345
In renal patients, what is MRI not useful for?
Poor detection of calcification and stones
346
Give three examples of isotope scans.
DMSA MAG3 Bone scan
347
What is a disadvantage of a PET-CT in Renal patients?
Limited use in staging urological malignancies
348
What is the best imaging modality to diagnose renal tract stones?
CT
349
A 65yo man with resistant hypertension and suspected renal artery stenosis. eGFR 55ml/min. What would b the initial test?
CT or MRI
350
What is the best imaging modality to stage renal tumours?
CT
351
What is the least helpful imaging modality in assessment of patient with suspected renal artery stenosis?
US
352
What would be the treatment for PUJ?
- Interventional radiology | - Surgery
353
What happens to drugs when there is impaired renal function?
Build of active drugs and metabolites
354
What kind of drugs are more likely to cause a problem with nephrotoxicity?
High Toxicity | Low TI
355
Give examples of drugs that can be nephrotoxic.
Gentamicin Digoxin Lithium Tacrolimus
356
How can drugs affect pharmacodynamics?
Alters action on tissues | Increase sensitivity to ADRs
357
How can drugs affect pharmacokinetics?
Decrease GFR Increase half-life Decrease protein binding
358
When should you worry about drug-induced nephrotoxicity?
``` Elderly Sick Volume depleted Hypotensive Prescribed a large no. of potentially reno-toxic agents ```
359
What should you do when nephrotoxicity is a concern?
Decrease dose Change dosing frequency Change drug
360
Why is hypertension and renal disease a problem?
Those with renal disease are more sensitive to hypotensive actions of drugs e.g ACEi, Thiazide-like diuretics, CCBs
361
Describe common renal damage induced by drugs.
ARF CRF Nephrotic syndrome Salt and water abnormalities
362
In relation to urea and creatinine levels, what can result with nephrotoxic drugs?
Asymptomatic increase
363
What is the most common renal problem resulting from drugs?
Acute tubular necrosis
364
What drugs most commonly causes acute tubular necrosis?
Aminoglycosides
365
What drugs can cause acute interstitial nephritis?
NSAIDs, Rifampicin, cocaine, penicillins
366
What drugs can cause crystal formation?
Acyclovir
367
What drugs can cause nephrotic syndrome?
Gold NSAIDs Interferon
368
What renal syndromes can be caused by NSAIDs?
``` ARF Hypertension Nephrotic syndrome Hyperkalaemia Papillary necrosis ```
369
What percentage of AKI hospital admissions are due to drugs?
20%
370
Describe the pathogenesis of aminoglycoside induced renal injury.
Proximal tubular injury --> cell necrosis
371
What is the most common composition of stones?
Calcium oxalate
372
Patients with uric acid stones are prone to what?
Gout
373
What are the symptoms and signs of stones?
- Renal pain (fixed in loin) - Ureteric colic (radiating to groin) - Dysuria/haematuria/testicular or vulval pain - UTI - Loin tenderness - Pyrexia
374
What are the investigations for stones?
- Bloods - Calcium, albumin, urate - Parathormone - Urinalysis and culture - 24hr urine collection
375
What radiological investigations are used for investigation stones?
- KUB plain radiography - USS - IVU - CT KUB - CT KUB/Urogram - 3D reconstrucion
376
What would be the first line radiological investigation for stones?
CT
377
Name 3 indications for surgery for stones?
- Obstruction - Recurrent gross haematuria - Recurrent pain and infection
378
What techniques are used for surgical treatment of stones?
- Endoscopic surgery - ESWL - PCNL
379
Where can stones exist in the urinary tract?
- Renal stones - Ureteric stones - Bladder stones
380
What are disadvantages of open surgery for stone removal?
Large scar, long hospital stay, general wound, long recovery
381
When is open surgery for stones indicated?
Non-functioning kidney with large stones necessitating nephrectomy
382
What technique is most commonly used for larger stones?
PCNL
383
When is PCNL indicated?
- Large stone burden - Associated PUJ stenosis - Cystine (ESWL resistant)
384
For PCNL, what is required for visualisation?
US, X-ray
385
What are contraindications for PCNL?
- Uncorrected coagulopathy - Acute UTI - Obesity
386
What are complications of PCNL?
- Psuedoaneurysm or AV fistula - UT injury - Systemic complications - Injury to adjacent organs
387
What are contraindications for ESWL?
Stones > 2cm
388
What are indications for open surgery for ureteric stones?
- Not suitable for endoscopic | - Failed ESWL or ureteroscopy
389
What are indications for ureteroscopy?
- Severe obstruction - Uncontrollable pain - Persistent haematuria - Failed ESWL
390
What is the first line treatment for bladder stones?
Endoscopic surgery
391
Name complications of ureteroscopy.
- Haematuria - Fever - Major ureteric perforation - Stricture formation
392
Name systemic diseases that affect the kidneys.
``` DM CVD Infection Myeloma Amyloidosis Inflammation of blood vessels ```
393
What is the commonest cause of ESRF?
Diabetic nephropathy
394
What is the most important risk factor for diabetic nephropathy?
Duration of hyperglycaemia (type doesn't matter)
395
What happens do protein in urine and GFR in diabetic nephropathy?
- Proteinuria increases | - GFR decreases
396
In relation to CKD, what are likely cardiovascular associated diseases?
- Hypertension - IHD - LVH
397
What is renal vascular disease?
Atherosclerosis of renal artery
398
What can cause artheroembolic disease?
- Eosinophilia - Peripheral skin lesions - Warfarin therapy - Vascular procedures
399
What is prescribed to treat microscopic polyarteritis?
Cyclophosphamide
400
What is affected in vasculitis?
Multiple organs
401
How is vasculitis named?
Aorta/large artery Medium artery Small vessels
402
Give examples of small vessel vasculitis?
Microscopic polyarteritis Wegner's granulomatosis
403
What are common presentations of Wegner's granulomatosis?
- Upper respiratory tract - Lower respiratory tract - Kidney - Joints - Eyes - Heart - Systemic
404
How do you diagnose vasculitis?
- Urine - Renal function - Biochemistry - Haematology - Immunology - Renal biopsy
405
Name an infection that is linked to glomerulonephritis.
Infective endocarditis
406
What suggests renal involvement in infective endocarditis?
- Abnormal urea/creatinine - Haematuria - Reduced compliment
407
Name a haematological malignancy linked to renal failure?
Multiple myeloma
408
What are clinical features of multiple myeloma?
Elevated ESR Anaemia Weight loss Fractures
409
What are signs of renal failure in myeloma?
- Cast nephropathy - Light chain nephropathy - Amyloidosis - Hypercalcaemia - Hyperuricaemia
410
When should you suspect systemic disease?
``` Fever Malaise Weight loss Arthralgia Vasculitic rash Breathlessness Haemoptysis ```
411
When should you suspect systemic disease with renal involvement?
- Hands: splinter haemorrhages, - Face:hypertensive retinopathy - Skin: rashes
412
What tests should be carried out for systemic disease wit renal involvement?
Bloods Urinalysis Radiology Biopsy
413
What is the commonest cancer in men?
Prostate cancer
414
What are risk factors fro prostate cancer?
Age Ethnicity Geography Family history
415
What is the risk of prostate cancer if first degree relative with prostate cancer?
2 x
416
In what zone of the prostate is 80% of cancers found?
Peripheral zone
417
Why is using PSA in prostate cancer screening problematic?
High sensitivity but low specificity i.e many false positives
418
What are symptoms of prostate cancer?
Most asymptomatic until locally advanced
419
What are symptoms of locally advanced prostate cancer?
``` Haematuria, Perineal and suprapubic pain Impotence Incontinence Loin pain or anuria Symptoms of renal failure ```
420
How do you avoid under-treatment of aggressive cancers?
Ad-hoc PSA testing
421
What causes a rise in PSA?
BPH | Increasing age
422
What produces PSA?
Glands of prostate
423
What is the normal serum level of PSA?
0.4ug/ml
424
What can cause an elevation in PSA?
``` UTI Chronic prostatitis Instrumentation Physiological BPH Prostatic Cancer ```
425
If rechecking PSA, when should this be done?
Within 3 weeks
426
What grading scores are used for prostate cancer?
ISUP Grade Group | Gleason sum score
427
How do you stage prostate cancer?
``` DRE PSA Transrectal US Guided biopsy CT MRI ```
428
What lymph nodes can prostate cancer spread to?
Internal iliac lymph nodes
429
What is the treatment for metastatic disease?
Hormonal therapy (lower testosterone)
430
What is the treatment for localised prostate cancer?
- Watchful waiting - Radiotherapy - Radical prostatectomy
431
How does testicular cancer usually present?
Painless lump
432
What are risk factors for testicular cancer?
- Young men (around 30) - Caucasians - Testicular maldescent - Infertility - Previous cancer in contralateral testis - Testicular germ cell neoplasia-in situ is a precursor
433
What are the investigations for testicular cancer?
- Examination - MSSU - Testicular USS and CXR - Tumour markers
434
What is the treatment for testicular cancer?
Radical inguinal orchidectomy
435
What is a biopsy used for in suspected testicular cancer?
Contralateral testis
436
During radical inguinal orchidectomy, where is the incision made?
Groin
437
What is the pathological cause of 95% of testicular cancers?
Germ cell tumours
438
What % of primary care consultations are due to UTI?
6%
439
Name general predisposing factors for UTI.
Immunosuppression Steroids Malnutrition Diabetes
440
Name UTI predisposing factors specific to the urinary tract.
- Female sex - Sexual intercourse - Congenital abnormalities - Foreign bodies - Oestrogen deficiency - Fistula between bladder and bowel
441
What is strangury?
Micturate often and little volume then urge
442
Name two urinary tract infections common in developing countries?
TB | Schistosomiasis
443
A 6 year old child presents with swelling of his face and legs. His serum albumin is low and has frothy urine. What is the most likely diagnosis?
Minimal change glomerulonephritis
444
A 23yo complains of flank pain, dysuria and frequency of micturition. She has taken ibuprofen for the pain. Her urinalysis shows protein, nitrates and blood. What is the likely diagnosis?
Acute pyelonephritis
445
A 40yo man was found to have asymptomatic proteinuria and microscopic haematuria during routine employment-related examination. His BP and serum creatinine was high. He has no urinary symptoms. What is the next important investigation?
Ultrasound of the urinary tract
446
A 60yo man has stage 5 CKD with a serum creatinine of 500umol/l. What is likely to be present?
High serum phosphate | Low serum calcium
447
Why is a high serum phosphate found in patients with progressive CKD?
Phosphate not filtered through glomeruli when there is a low GFR
448
What do you give to CKD patients to prevent hypophosphataemia?
Phosphate binders
449
Why is there low serum calcium in CKD?
25 (OH) Vit D deficiency which is needed to absorb calcium.
450
What can hypocalcaemia in CKD lead to?
Hyperparathyroidism
451
Patients with renal failure are often anaemic, what is the best treatment for this?
Erythropoietin
452
A 70yo man complains of poor stream of urine, nocturia and post-micturition dribbling. What is the most likely cause?
Prostatic hypertrophy
453
A 60yo man presents with tiredness and malaise. Routine investigations show raised serum creatinine and an eGFR 35ml/min. What stage of CKD does he have?
3b
454
What is the commonest urological malignancy in patients with painless frank haematuria?
Bladder cancer
455
What is the commonest type of renal tract stone in adults?
Calcium oxalate
456
What is the commonest mode of presentation for patients with a renal ureteric stone?
Loin pain radiating to the flank and/or groin
457
What are the features of acute urinary retention?
Painful inability to void with a palpable or permissible bladder
458
What antibiotic is not suitable for empirical treatment of complicated UTI?
Vancomycin
459
Why is vancomycin not generally suitable for empirical treatment of complicated UTI?
Only acts against gram positive bacteria (UTIs are most commonly gram negative)
460
When is gentamicin used to treat UTIs?
Complicated UTIs
461
If a patient presents with back pain and AKI, what should you test for?
Myeloma screen
462
How do NSAIDs function in relation to the kidney?
NSAIDs block prostaglandins which normally dilate the afferent arteriole. Therefore, constrict afferent arteriole and decrease perfusion.
463
If you block angiotensin 2, what will happen to the GFRr?
Fall especially when used with NSAIDs
464
What tests should be screened for when assessing for organ donation?
- Haematology - Tissue typing - U&Es/LFTs, amylase and phosphate - Virology (e.g HIV, vCJD, EBV)
465
What core donor data is needed pre organ donation?
- BGs on O2% and 100% - All drugs on and given - Fluid status/haemodilution - Evidence of BSD - Haemodynamic stasis - Physical examination
466
What are the two types of offerings in organ donation?
- National | - Super urgent
467
What are the main steps in organ donation planning?
- Donor identification - Approach to relatives/families - Screening - Core donor data - Electronic offering - Donor management - Follow-up
468
Name 5 types of living organ donation.
- Blood relative - Relative by marriage - Friend - Paired - Altruistic
469
If an individual is in respiratory acidosis, what ion will they be excreting large quantities of?
Ammonium
470
A patient who has metabolic alkalosis will be excreting lots of what ion?
Bicarbonate
471
What is uraemia a sign of?
Renal failure
472
When is it appropriate to give bicarbonate?
Metabolic alkalosis only
473
If osmolarity is normal and hyponatraemia, what is this?
Pseudohyponataremia
474
What does spironolactone do?
Inhibit sodium reabsorption in distal tubule
475
Why is there hyperphospahaemia in chronic renal failure?
Phosphate not filtered
476
What is given to prevent hyperphosphataemia in patients with chronic renal failure?
Phosphate binders
477
Why do you have a low serum calcium in chronic renal failure?
Need vitamin D, since this is lacking you don't absorb calcium
478
What presents with slow stream micturition with terminal dribbling and frequency?
Chronic retention with overflow causing severe hydronephrosis

Urinary (2 decks)

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