Genitourinary Flashcards

Question

Staging of testicular cancer includes:

Answer 1

* TNM staging * Also has an S classification which includes present of tumour markers - LDH, hCG, AFP

Answer 2

* Removal of the affected testicle is urgent * Ca testis = one of the fastest doubling times of all malignancies * Patient should be referred to urologist without delay * Urologist removes testicle + cord through inguinal canal, rather than the scrotum * Enables early control of venous drainage prior to manipulating * Avoids seeding the scrotal tissues with cancer cells * Removes initial lymphatic drainage pathway of testicle (via cord) * Most patients have chemotherapy or radiotherapy after orchidectomy * Depends on stage – surveillance may be offered for stage I * Depends on tumour subtype * Seminoma are very radiosensitive and chemosensitive * Non-seminomas are very chemosensitive _Prior to treatment_ * Patients should be offered sperm banking * Serum markers should be sent * Patients disease should be staged (CT chest/ abdomen and pelvis) * Patient may be offered a prosthesis (artificial testicle) by their urologist _After treatment_ * Patient require prolonged follow up (10y+) * Recurrence can occur many years down the track

Answer 3

**Mechanical obstruction** * Enlarged prostate * Benign Prostatic Hypertrophy * Prostate cancer * Acute prostatitis * Urethral Narrowing * Urethral stricture * Urethral carcinoma * Posterior urethral valves * Urethritis * Meatal stenosis (rare) * Bladder neck obstruction * Bladder calculi * Urothelial cancer * Urinary bladder tamponade * Phimosis and paraphimosis * Blocked catheter **Functional** * Detrusor underactivity and/or sphincter overactivity * Neurological Causes * CNS * Stroke * Spinal cord compression * Multiple Sclerosis, Parkinson’s Disease * Peripheral nervous System * Damage to pelvic splanchnic nerves (bladder denervation) à causes ¯ bladder sensation and detrusor contractility à infrequent, incomplete urination à overflow incontinence * Diabetic autonomic neuropathy * Trauma (pelvic fracture, surgery/ radiation of pelvis) * Drug-induced urinary retention * Due to detrusor underactivity: anticholinergics, tricyclic antidepressants, antipsychotics, calcium channel clockers, antiparkinson agents * Due to increased urethral sphincter tone: sympathomimetic agents, nonselective beta blockers, opioids * Detrusor-sphincter dyssynergia * Urethral/ bladder trauma (urethral transection) * Post-op urinary retention

Answer 4

**Acute** * More common in men \>70 * Sudden, painful inability to void despite having a full bladder * Suprapubic pain/ discomfort; palpable bladder * Patient is restless and distressed **Chronic** * Females \> males * Chronic, painless incomplete voiding of the bladder * Palpable bladder may be present * May present with overflow incontinence or nocturnal enuresis

Answer 5

**Lab studies** 1. Urinalysis and culture – evaluate for UTI, haematuria, glycosuria, and crystals 2. U&E – BUN (Blood urea nitrogen, Creatinine levels, electrolytes): evaluate for renal failure (obstructive nephropathy) 3. PSA – serum prostate specific antigen 4. BSL - glucose control in known diabetics or if diabetic neuropathy is suspected **Imaging** 1. U/S of kidney, ureter and bladder (indicated in all patients with urinary retention) * AUR – bladder distented with \> 400mL or urine * CUR – post void residue \> 300mL; bladder wall thickening * In both evaluate for hydroureteonephrosis; diagnose bladder calculi or BPH **Further investigations** 1. Transrectal U/S – prostate cancer 2. Cystoscopy – suspected bladder cancer (gross haematuria) 3. Retrograde urethrogram or voiding cystourethrogram – urethral trauma, stricture, tumours 4. Pelvic U/S 5. MRI brain or spinal cord 6. Urodynamic studies

Answer 6

RCC arises from renal tubular epithelium, is the most common cause of renal malignancy in adults (85%) Risk factors * Smoking * Family history * Certain pre-existing conditions * Renal pelvic stones * Obesity * Hypertension * Acquired cystic kidney disease as a result of ESRD * Immunodeficiency * Sickle cell disease * Chronic hepatitis C infection * Occupational exposures * Occupational exposure to cadmium, asbestos and/ or petroleum * Chemotherapeutic agents (cisplatin) during childhood * Chronic analgesic use (aspirin, acetaminophen)

Answer 7

Classic triad of: * Haematuria * Flank pain * Abdominal mass Also: * Anaemia (common), pallor, lethargy * Constitutional symptoms: weight loss, fatigue, night sweats RCC asymptomatic in early stages. Patients become symptomatic when the tumour has reached a large size (usually \> 10cm) and/ or if metastases are present Paraneoplastic syndromes: * Hypertension * Hypercalcaemia * Polycythemia, leukemoid reaction * Secondary hypercortisolism

Answer 8

**Imaging** 1. Abdominal CT scan with contrast 2. Renal U/S Evaluation of metastatic disease 1. CT/ MRI of the thorax 2. Bone scan **Lab tests** 1. Urinalysis – haematuria 2. Hb levels and FBC 3. Hypercalcaemia 4. Raised AST, ALT and/ or ALP 5. BUN/ creatinine 6. Percutaneous renal biopsy is generally not recommended

Answer 9

Surgical resection of the tumour * Stage I: cryoablation, thermal ablation, partial nephrectomy, or simple nephrectomy * Stage II-IV: radical nephrectomy RCC is resistant to chemotherapy and radiotherapy New drugs * Interferon-alpha * Tyrosine kinase inhibitors e.g. sorafenib, sunitinib

Answer 10

Benign prostatic hyperplasia * Refers to increased prostate size due to increased cell number (NOT bigger cells) * This hyperplasia of prostatic stromal and epithelial cells results in nodular growth in the prostatic urethra Epidmeiology * 50% of 50-60yo * 80% of 80yo

Answer 11

Continued enlargement can block the urethra, which can cause lower urinary tract symptoms (LUTS) * Frequency * Incomplete emptying * Hesitancy * Intermittency * Urgency * Weak stream * Straining * Nocturia BPH = Bladder outflow obstruction + lower urinary tract symptoms + benign prostatic enlargement

Answer 12

* Urinary retention * UTI * Urosepsis * Urinary bladder stone * Obstructive uropathy and renal failure

Answer 13

* **History of LUTS** - IPSS is commonly used symptom score * **Rectal examination** - smooth enlarged prostate * **PSA** - very low PSA makes BPH unlikely. Prostate cancer may co-exist. Note: PSA elevated is not diagnostic of BPH or prostate cancer. It is reported symptoms, imaging, urodynamics and sometimes prostate biopsy that leads to diagnosis of BPH * Trans-rectal U/S and biopsy - a prostate biopsy is performed to detect prostate cancer in patients with an abnormal DRE and/ or increased PSA. A negative biopsy helps confirm a diagnosis of BPH _PSA_ * Is a serine protease produced by the prostate involved in the liquefaction of sperm * Is prostate specific but not cancer specific * Serum PSA increases with age, increasing size of prostate and in prostate cancer * Serum PSA can be elevated in urinary infections or after surgical instrumentation _IPSS – International Prostate Symptom Score_ * Based on 7 questions and gives a measure of symptoms and how badly these symptoms are affecting life * It also allows urologists to assess patients response to therapy and disease progression * Score of 0-7 = mildly symptomatic, score 8-19 = moderate, 20-35 = severe * IPSS does not establish a diagnosis of prostate cancer or BPH * Questions: * Incomplete emptying * Frequency * Intermittency * Urgency * Weak stream * Straining * Nocturia

Answer 14

**Medical Treatment of BPH** 1. _Alpha Blockers (Alpha1-adrenergic antagonist)_ * *Prazosin, tamsulosin 0.4mg OD* * Tamsulosin is more uro-selective * Relaxes smooth muscle in the prostate gland and bladder neck improving urinary flow * Common side effect is Postural Hypotension 1. _5 alpha-reductase inhibitors_ * *Finasteride (Proscar) 5mg OD, Dutasteride* * Inhibits 5a-reductase, an enzyme which is responsible for the conversion of testosterone to dihydrotestosterone (DHT) in prostate * DHT is known to be responsible for the enlargement of the prostate gland * It is also used for the treatment of male pattern baldness * Side effects (approx. 5 %): erectile dysfunction, loss of libido, breast tenderness * 2 drugs are available – finasteride and dutasteride which reduce DHT production by inhibiting one or both of the isoenzymes of 5 alpha reductase respectively 1. _Anticholinergics_ * Treat symptoms of over-active bladder (Storage symptoms) * Common side effects include dry mouth and constipation. Rarely blurred vision and confusion * Contra-indicated in glaucoma, avoid in the elderly * May precipitate urinary retention (avoid in bladder outflow obstruction) \*A combination of alpha-blocker and a 5-alpha-reductase inhibitor is sometimes required **Surgical treatment of BPH** _Indications for surgery_ * Severe symptoms * Failed medical treatment * Complications of bladder outflow obstruction: urinary retention, bladder stones, UTI, upper tract obstruction/ renal impairment _Types of surgery_ There are several types of surgery available 1. Transurethral resection of the prostate (TURP) 2. Laser ablation/ resection 3. Open prostatectomy _TURP_ * Patient has mainly storage symptoms not voiding symptoms * Performed under spinal or GA * Involves inserting a cystoscope and an electrical loop that cuts and diathermies bleeding vessels in the prostate gland * Irrigation fluid is also passed through the cystoscope. Commonly used irrigation fluid is glycine * Prostate chips that have been removed will be sent off for histopathology * Patients are expected to stay in hospital for approximately 1-2 days post-op. recovery for most patients is about 2 weeks * IDC is inserted at end of operation and remains in-situ for the first 24-hour post-op Risks * Bleeding, infection, retrograde ejaculation, erectile problems, urinary incontinence, bladder neck stricture * TURP syndrome. This is a dilutional hyponatraemia after absorption of hypotonic irrigation solution used during the procedure. When to think hard/ investigate further before offering TURP? * Over 80s and under 50s * Possible neurogenic cause for symptoms (CVA, diabetic) * Previous TURP

Answer 15

Testicular torsion is the sudden twisting of the spermatic cord within the scrotum. It most commonly affects children and young men. Because of the risk of ischaemia and possible infarction of the testicle, it is considered a urological emergency. _Bell-Clapper Deformity_ High fusion of tunica vaginalis means testicle lies loose in bell-clapper configuration * Enables testicle to twist around on its blood supply * Bell clapper testicles tend to be high riding with a horizontal lie

Answer 16

* Abrupt onset testicular pain and/ or pain in the lower abdomen * Typically swollen and tender testicle and/ or lower abdominal tenderness * Nausea and vomiting * Abnormal position of testicle * Abnormal transverse lie * Scrotal elevation * Possible undescended testes (predisposes to testicular torsion) * Absent cremasteric reflex * Prehn sign: negative * Positive if lifting the testicle relives pain (typical for epididymitis), negative if it doesn't (typical for testicular torsion). \*Testicular torsion should always be suspected in a male patient with severe, sudden-onset testicular pain

Answer 17

If there is clinical suspicion of torsion, patient should be referred to Urology without further investigation Lab tests * Urine dipstick to exclude epididymitis * Inflammatory markers in case of epididymitis, FBC, UEC U/S * Indications: ambiguous clinical findings, low suspicion of testicular torsion * Doppler U/S reduced perfusion in the affected testicle \*Surgical intervention is recommended for suspected testicular torsion, regardless of radiological findings

Answer 18

Emergency exploration of **BOTH testis**, torted side first * Testicle is immediately de-torted * Viability assessed after warming in saline packs * Testis viable after de-torsion – 3 point fixation (**orchidopexy**) to pin testicle and tunica vaginalis onto dartos muscle of the scrotum * Contralateral side also explored and fixed because this condition is BILATERAL * Failure to treat the other side will result in future torting of the untreated testicle * Testis non-viable after de-torsion -- orchidectomy and then fixation of contralateral side

Answer 19

* infertility * testicular cancer * testicular torsion * inguinal hernia

Answer 20

Surgery is recommended between 6-18 months of age * Orchidopexy: exposure and fastening of the testicles to the scrotum * Non-palpable testes: potentially therapeutic open or laparoscopic orchidopexy

Answer 21

Vesicoureteral reflux is the retrograde flow of urine from the bladder into the ureter. Primary VUR is the most common type and is due to a congenital defect of the terminal portion of the ureter. Epidemiology * Incidence: 1% of newborns * Prevalence of VUR * Among children with UTIs: 30-45% * Among neonates with prenatal hydronephrosis: 15% * Age; children \< 2 * Females \> Males (2:1) * More common in white children

Answer 22

Primary VUR (Most common): Short intramural ureter - vesicoureteric junction (VUJ) fails to close completely during bladder contraction - VUR Secondary VUR * Bladder outlet obstruction (anatomic/ functional): high pressure within the bladder - reflux of urine through the VUR * Anatomical: Posterior urethral valves; urethral meatal stenosis * Functional: bladder and bowel dysfunction; neurogenic bladder * Cystitis * Congenital anomalites of the ureter * Ureteral duplication * Ectopic ureter * Ureterocele

Answer 23

* Suspected in the prenatal period when hydronephrosis is detected on routine antenatal U/S * Postnatal presentation * Recurrent febrile UTIs * Neonates: irritability, fever, listlessness * Older children: urinary urgency, frequency, incontinence, dysuria associated with fever * Reflux nephropathy (A type of interstitial nephritis): renovascular hypertension, kidney failure, uraemia * Flank or abdominal pain before or during voiding \*VUR is generally asymptomatic until it causes a UTI

Answer 24

**Lab studies** * Urinalysis and urine culture: indicated in all children with hydronephrosis to rule out infection * UEC * [Uremia](https://www.amboss.com/us/library#xid=lg0vv2&anker=Zd1ef7f80d291ea05f20d22e484b026f2) may be present in bilateral VUR because of renal parenchymal scarring (secondary to reflux of infected [urine](https://www.amboss.com/us/library#xid=Rp0l6S&anker=Z3a9be6d77b8ac1229882a1913aa48e90)) or an associated congenital [renal hypoplasia](https://www.amboss.com/us/library#xid=Oi0I7f&anker=Z8db5f4b32bf68e7f6242fef0c77de778). **Imaging** 1. U/S * indicated in children with febrile UTI * detection of hydronephrosis and dilater ureter 1. Contrast voiding cystourethrogram * Indicated for children with \> 2 episodes of febrile UTI, or UTI with hypertension, significant fever * Contrast instilled through urethral catheter. Retrograde reflux of contrast into ureters during micturition is diagnostic of VUR 1. Urodynamic testing to evaluate secondary VUR * A group of tests to assess function of the urinary tract and to identify sites of obstruction. Includes cystometry (evaluates bladder function during filling, storage, and voiding), uroflowmetry (evaluates rate of urine flow), and urethral tests (evaluate intrinsic sphincter function). Indicated in the diagnostic workup of lower urinary tract dysfunction and for the planning of surgical treatment.

Answer 25

**Conservative** Indicated for VUR grades I-III in children \< 5 years of age 1. Long term prophylactic antibiotics * Children \> 3mo à nitrofurantoin * Infants à amoxicillin 2. Behavior modification e.g. timed voiding, prevention of constipation 3. Surveillance: urinalysis, renal imaging **Surgical** Indicated for VUR \>= grade IV. Bilateral grade III, especially children \> 6yo. OR worsening renal function/ breakthrough UTIs despite prophylactic antibiotics 1. Subureteric transurethral injection 2. Ureteral reimplantation

Answer 26

Inflammation of the prostate gland that may be infectious (acute and chronic bacterial prostatitis) or non-infectious (Chronic pelvic pain syndrome) _Bacterial prostatitis_ Gram-negative bacteria, particularly E.coli and other Enterobacteriaceae Risk factors: * other genitourinary tract infections e.g. urethritis, cystitis, epididymitis * genitourinary tract interventions e.g. indwelling catheter, transurethral surgery _Chronic pelvic pain syndrome_ No detectable causative organism. The exact aetiology unknown

Answer 27

Acute bacterial prostatitis * fevers, chills * acute dysuria, frequency, urgency, cloudy urine * severe genitourinary pain * prostate is tender and swollen Chronic bacterial prostatitis * chronic bladder irritation - dysuria, frequency, urgency * mild genitourinary pain Chronic pelvic pain syndrome * moderate genitourinary pain

Answer 28

**Lab tests** _Acute bacterial prostatitis_ 1. Urinalysis using MSU * Raised WCC, urine culture, urine gram stain (E.coli most commonly seen) 2. Blood tests * Raised inflammatory markers * Raised PSA 3. Blood cultures is sepsis suspected _Chronic bacterial prostatitis_ Stamey test – sequential urine cultures (not really used anymore) * Voided bladder 1: initial 5-10mL or urine specimen   * Voided bladder 2: clean-catch midstream urine specimen   * Expressed prostatic secretions; secretions expressed from prostate by digital massage after  midstream urine specimen   * Voided bladder 3: first 5-10 mL of urine stream immediately after prostatic message   Further tools * Urethral swab and culture * U/S to assess residual urine * Cystoscopy

Answer 29

1. Fluroquinolones (ciprofloxacin) 2. Suprapubic catheterization in cases of acute urinary retention and persistent fever

Answer 30

Painless accumulation of fluid in a sac around one or both testicles which derived from the tunica vaginalis, a tissue covering the testes. Features * Fluctuant, painless swelling of affected scrotum * May be present since infancy or childhood * May or may not be reducible * Palpation above the swelling is possible (not the case in hernia): a normal spermatic cord and inguinal ring are present * Positive transillumination

Answer 31

Usually clinical 1. Inguinoscrotal U/S is highly sensitive, specific, reliable and reproducible. It should be performed to confirm diagnosis and exclude malignancy When diagnosing hydrocele it is important to exclude testicular ancer, infection/ abscess, trauma/ rupture of testis

Answer 32

Usually resolves spontaneously within 6 months of birth Indications for surgery: * If spontaneous resolution does not occur in children by 1 year of age * Excessive discomfort and/ or if scrotal skin integrity is compromised * An underlying pathology is suspected * Testicle not palpable * If infertility is a concern Procedures * Aspiration rarely indicated as risks infection and collection rapidly recurs * Surgery e.g. hydrocoelectomy with plication and/ or eversion of tunica vaginalis are used most commonly * Recurrence rate is low * Post-op haematoma is a common complication

Answer 33

Abnormal enlargement and tortuosity of the pampinoform plexus in the scrotum due to proximal obstruction the spermatic vein. Features * May be painless enlargement * Dull, aching pain of the hemiscrotum (**typically left-sided**) * Heaviness of the affected scrotum * Soft bands/ strands are palpable in the upper pole of the affected scrotum (feels like a bag of worms) * Symptoms worsen when standing or when performing a Valsalva maneuver * Negative transillumination

Answer 34

**Investigations** 1. Inguinoscrotal U/S is highly sensitive, specific, reliable and reproducible. It should be performed to confirm diagnosis and exclude malignancy When diagnosing varicocoele it is important to measure size of testis and check the kidneys for tumour (occassionally cause varicocoele) **Causes** * Primary * Mainly left‑sided: the left spermatic [vein](https://www.amboss.com/us/library#xid=ZK0ZUS&anker=Z6f8d5f3537f44c7bd7f1915d726b6360) is a long [vein](https://www.amboss.com/us/library#xid=ZK0ZUS&anker=Z6f8d5f3537f44c7bd7f1915d726b6360) with high pressure because of its position between the aorta and [superior mesenteric artery](https://www.amboss.com/us/library#xid=R60lkS&anker=Zbd73768ac25cd57aae7b69c63c8adf99). Dilation of the spermatic [vein](https://www.amboss.com/us/library#xid=ZK0ZUS&anker=Z6f8d5f3537f44c7bd7f1915d726b6360), which is positioned perpendicular to the renal [vein](https://www.amboss.com/us/library#xid=ZK0ZUS&anker=Z6f8d5f3537f44c7bd7f1915d726b6360) → obstruction of the spermatic [vein](https://www.amboss.com/us/library#xid=ZK0ZUS&anker=Z6f8d5f3537f44c7bd7f1915d726b6360) → poor outflow of blood and stasis → [varicocele](https://www.amboss.com/us/library#xid=ni07Hf&anker=Z3f25572c35f89ec156ebaeae12ec5ca5) * Secondary * Bilateral manifestations may occur. A secondary [varicocele](https://www.amboss.com/us/library#xid=ni07Hf&anker=Z3f25572c35f89ec156ebaeae12ec5ca5) may be caused by a mass in the [retroperitoneal](https://www.amboss.com/us/library#xid=M60MlS&anker=Z1a027dd7df9ef92646d4b8b922e30e36) space ([Ormond’s disease](https://www.amboss.com/us/library#xid=9h0NTf&anker=Z03f0142bdc8116a585676a7b55dcd8cb), lymphoma) or a thrombotic event (e.g., pampiniform plexusobstruction in [renal cell carcinoma](https://www.amboss.com/us/library#xid=Ki0Usf&anker=Z84c07736f386e66e0b0ac35727f0a831)). Secondary [varicoceles](https://www.amboss.com/us/library#xid=ni07Hf&anker=Z3f25572c35f89ec156ebaeae12ec5ca5) persist in the supine position due to a physical obstruction to blood flow within the spermatic [vein](https://www.amboss.com/us/library#xid=ZK0ZUS&anker=Z6f8d5f3537f44c7bd7f1915d726b6360).

Answer 35

Invasive treatment indications: * Adolescents with testicular atrophy or delayed growth of the affected testivle * Adult men with evidence of infertility (confirmed with an abnormal sperm analysis) Procedure: Laparoscopic varicocelectomy or percutensous embolization Conservative management (indicated in older patients) 1. NSAIDs 2. Scrotal Supports Young men without testicular atrophy or evidence of infertility should recive follow ups (regular assessment of testicle size and/ or semen analysis every 1-2 years)

Answer 36

1. **Cystitis** – infection of the bladder (lower urinary tract infection) 2. **Pyelonephritis** – infection of the parenchyma and collecting system of the kidney (upper urinary tract infection) 3. **Asymptomatic bacteriuria** – significant bacteriuria present in the urine with no symptoms (usually seen in children, pregnant and elderly)

Answer 37

* Female - shorter urethra * Sexually active * Menopause, pregnancy * Renal calculi * Vesicoureteral reflux * Immunocomprimise * Age - small kids, pregnant, older age * Residual bladder in urine * neurogenic bladder * urethral stricture * BPH * Instrumentation of the urinary tract * IDC * Cystoscopy * Urethral dilation

Answer 38

Community acquired * Escherichia coli * Staphylococcua saprophyticus * Less commonly Proteus Enterobacter _Hospital acquired_ * E.coli * Enterobacteriaceae * Pseudomonas aeruginosa * Enterococcus faecalis

Answer 39

Cystitis * Dysuria * Frequency * Urgency * Urine is turbid, may smell offensive, may be bloody Pyelonephritis * Flank or back pain * fevers, chills, rigors * headache, nausea, vomiting * dysuria, frequency, urgency

Answer 40

Urine can be easily contaminated by the same bugs that cause UTIs. 1. _Urine dipstick_ * Nitrate and leukocyte esterase positive 1. _Urine microscopy_ * White Cells * Values above 10x10^6 indicate inflammation of urinary tract * If urine left standing, leucocytes breakdown, so prompt processesing * Elevated WCC in urine = pyuria --\> cloudy beer appearance * Red cells * Indicate bleeding in urinary tract (calculi, tumours, inflammation, infection); or from being extruded through damage glomeruli (glomerulonephritis) * Extruded red cells from glomeruli have bizarre morphologies * Red cells with normal morphology seen in UTI * Note menstruations is common source of red cells * Squamous epithelial cells * Originate outside urinary tract, presence indicates contamination 1. _Urine culture_ * Quantitative culture; UTI if: * Adult female: \> 10^2/mL (\>10^5/L) * Adult males: \> 10^3/mL

Answer 41

**Cystitis** * Amoxicillin * Augmentin * Cephalexin 500mg orally, 12 hourly for 5 days * Nitrofurantoin 100mg orally, 6-hourly for 5 days * Trimethoprim 300mg orally, daily for 3 days * Norfloxacin **Pyelonephritis** Non-severe --\> Amoxicillin + Clavulanate 875+125mg orally, 12 hourly for 14 days Severe --\> Gentamicin IV + amoxicillin

Answer 42

An estimated or measured GFR \< 60mL/min/1.73m^2 that is present for \> 3 months with or without evidence of kidney damage 1. Evidence of kidney damage with or without decreased GFR that is present for \> 3 months as evidenced by the following: * Albuminuria * Haematuria after exclusion of urological causes * Structural abnormalities (e.g. on kidney imaging tests) * Pathological abnormalities (e.g. renal biopsy)

Answer 43

* 60 years or older * Diabetes * Family history * Established CVD * Hypertension * Obese * Smoker * Indigenous * History of AKI

Answer 44

* Diabetic nephropathy (1/3^rd) * Glomerulonephritis * Hypertensive vascular disease * Polycystic kidney disease * Reflux nephropathy * Other – vasculitides etc.

Answer 45

**Symptoms** * Stages 1-3 often asymptomatic * Fatigue * Nausea * Loss of appetite * Haematuria * Oedema * Muscle weakness * Anaemia * SOB * Peripheral neuropathy * Oliguira **Complications** N – Nitrogen 1. Uraemic Pericarditis, Pleuritis, Encephalopathy E – Electrolytes 1. **Hyperkalaemia** – Normal maintained unless aldosterone secretion (ACEIs, ARBs, B-blockers). Treat with insulin and risonium) 1. **Hyperphosphataemia** – early in disease course. As GFR decresses phosphate is excreted. 1. **Hypocalcaemia** – hyperphosphataemia suppresses the renal hydroxylation of inactive 25-hydroxyvitamin D to calcitriol, calcitriol usually stimulates the absorption of Ca++ from the GI 1. **Hyperparathyroidism** – secondary to hyperparathyridism in response the hypocalcaemia caused by CKD P – pH 1. **Metabolic acidosis** – H+ ions buffered into cells, RBCs, bones and albumin buffer H – Hypertension 1. **HTN** – Decreased GFR results in increased renin secretion and stimulation of the RAAS. Fluid retention and HTN which further worsens kidney disease. 2. **CVD risk factor** R – Red Blood Cells 1. **Anaemia** – Normochromic Normocytic Anaemia. Decreased renal synthesis of EPO that stimulates BM cells to produce RBCs decreases bone and bone marrow quality-renal osteodystrophy. Anaemia of chronic disease. O – Osteodystrophy and Oedema 1. **Renal osteodystrophy** – high bone turnover lesions with increased PTH secretion (oseitis fibrosa). Given vitmain D. bisphosphonates – complications long term. 1. **Volume overload** – kidneys responsible for excreting Na+ and water. As function declines there is Na+ and thus water retention and extracellular volume expansion leading to peripheral oedema and HTN. Clinical manifestations of volume overload occur in severe CRF \< 15. Tubulointerstitial disease can cause fluid loss rather than overload. N – Nephrotoxic drugs need to be stopped 1. **Pericarditis** – due to uraemia

Answer 46

1. **Blood tests** 1. UEC 1. Creatinine – increased 2. eGFR 3. Urea 4. Electrolytes – hyperkalaemia, hyperphosphataemia, hypocalcaemia 5. Bicarbonate, pH – metabolic acidosis 2. Calcitriol (vitamin D) – decreased 3. PTH – increased (Aiming to lower to 2-3 times upper normal, if not managed à adynamic bone desease) 4. Coagulation testing – increased bleeding time 5. Fasting lipids – patients at CVD risk \*\*CVD is what kills most patients with CKD\*\* 6. FBC - Hb * Anaemia of chronic disease (Decreased MCV) * Function of kidney is to produce EPO 1. **Urinalysis** – albuminuria, urine sediment abnormalities 2. **Ultrasound** * Shrunken kidneys and fibrotic parenchyma, hydronephrosis * Polycystic kidney disease? * In diabetes – kidneys tend to be larger 1. CT – masses + cyst 2. **Renal biopsy** to confirm specific diagnosis of CKD – histological abnoramlaities (See Diabetic nephropathy for an example)

Answer 47

**N - Nitrogen and sodium low diet** * Sodium restriction in patients with oedema or hypertension * Monitor fluids and body weight to prevent oedema **E – Electrolyte monitoring** * Treat hyperkalaemia – risonium (potassium binder) * ECG changes - peaked T waves, flatted P waves, long PR * Hyperphsphataemia – phosphate binding medications * PTH axis controlled **P – Ph monitoring and Proteinuria** * Can reduce proteinuria by stating on ACE-I or ARB – big improvement in mortality **H – Hypertension Treatment** **R – Red blood cells** * synthetic EPO à Dabapoitein * Iron replacement, monitor serum ferritin **O – Osteodystrophy** * Calcium supplementation + Vitamin D * PTH goes very high, try keep it down to no more than 3 times normal high limit **N – Nephrotoxic drugs stopped** * NSAIDs, nicotine, acyclovir, vancomycin, cisplatin, contrast _Additiona…_ **Reduce CVD risk** * Smoking cessation * Activity, diet * Statin, antihypertensive **Treat Underlying Cause** * Manage Diabetes, monitor HbA1c (increase insulin) **If Significantly Fluid overloaded** * Frusemide – 200mg BD IV * Monitor fluid levels and daily weights **Vaccination** * For influenza (yearly) and pneumococcal (5 yearly) **Progression to Dialysis** * Absolute Indications – pericarditis (pericardial rub), pleuritis, uraemic encephalopathy * Other indications – GFR \< 15 and symptomatic * Types of dialysis * Peritoneal (continuous or nightly) * Haemodyalysis – usually a few days a week at hospital (4 hour sessions) Transplant?

Answer 48

* pH and volume regulation, Electrolyte balance * BP regulation * Endocrine function --\> EPO * vitamin D synthesis * Control rate of RBC production * Remove metabolic waste

Answer 49

**_Pre-renal_** * Absolute decrease in circulating blood volume - dehydration, blood loss * Cardiac pump failure - MI, CCF * Effective decrease in blood volume - _Sepsis_, neurogenic, Vasodilatory drugs (NA, Adren) * Obstruction to circulation - Constrictive pericarditis, cardiac tamponade, PE * Locally reduced renal perfusion - Renal artery or vein occlusion **Renal** * Acute tubular necrosis * glomerulonephritis * Interstitial nephitis **Post-renal** * Ureter - stone, blood clot, tumour * Lower - BPH, urethral stricture * Blocked catheter

Answer 50

* Symptoms of underlying illness causing AKI * Oliguria or anuria * Lethargy * Vomiting * Oedema * Weight loss/ anorexia * Sleep disturbances * Pruritis

Answer 51

1. **Blood tests** * Creatinine - Acute increase in serum creatinine and decrease in urine output * FBC – anaemia or leukocytosis * VBG - Metabolic acidosis * U&E – Hyperkalemia (ECG), hypocalcaemia * BUN: Creatinine ratio * Raised - pre-renal, lowered - renal 1. **Urinalysis** * Albuminuria * RBCs, WBCs, cellular casts, proteinuria, bacteria, positive nitrite and leukocyte esterase 1. Urine microscopy – reveals hyaline casts in pre-renal AKI 2. Urine culture 3. U/S – may reveal urinary tract obstruction 4. Biopsy – in suspected rapidly progressive glomerulonephritis 5. CXR if suspect pulmonary oedema from fluid retention

Answer 52

Any of the following * Rise in creatinine \> 26umol/L in 48 hours * Rise in creatinine \> 1.5 baseline * Urine output \< 0.5mL/kg/hr for \> 6 consecutive hours * Urine output \< 400mL/24 hours

Answer 53

1. Treat underlying cause 2. General stuff * Review medications and cease nephrotoxic drugs * Monitor and correct electrolyte imbalances and acidosis e.g. hyperkalemia, pH * Volume overload - diuresis * Remove outflow obstructions e.g. catheterization. Insert a new one and monitor fluid balance * If necessary - dialysis Pre-renal * Blood loss requiring crystalloid or colloid?

Answer 54

Common infectious causes in men \< 35: * Neisseria gonorrhoea * Chlamydia trachomatis Common infectious causes in men \> 35: * E. coli * Other coliforms * Pseudomonas species

Answer 55

1. Gram stain or urethral secretions à presence of gram –ve diplococci 2. Urine dipstick test – positive leukocyte 3. Urine microscopy 4. Urine culture 5. NAAT or urethral secretion or first void urine for chlamydia and gonorrhoea **Treatment** * Gonorrhoea - Ceftriaxone 500mg IMI or IVI plus azithromycin * Chlamydia - Doxycycline 100mg for 7 days +/- ceftriaxone 300mg IMI for gonorrhoea

Answer 56

Neurological causes * Multiple sclerosis * Parkinson’s disease * Stroke * Dementia * Spinal injury Genitourinary causes * Trauma to the pelvic floor * Intrinsic sphincter deficiency * Urethral hypermobility in women * Impaired detrusor contractility * Bladder outlet obstruction e.g. bladder cancer * Pelvic floor weakness * Urogenital fistula * Renal stones DIAPPERS (reversible causes of incontinence) D – Delirium I – Infection A – Atrophic Urethritis/ vaginitis P – Pharmaceutical e.g. diuretics P – Psychiatric causes (depression) E – Excessive urinary output (hyperglycaemia, CHF) R – Restricted mobility S – Stool impaction

Answer 57

* Stress - increased abdominal pressure --\> urination e. g. weak pelvic floor muscles * Urge incontinence - inflammatory or neurogenic conditions * Overflow incontinence - impaited detrusor contractibility, outlet obstruction * Functional incontinence

Answer 58

Neurological, vaginal and rectal exam Voiding diary to assess frequency and volume of micturition review medications _Lab tests_ 1. Urine MC&S – to exclude urinary tract infections 2. Urea and electrolytes 3. Creatinine and blood urea nitrogen (BUN) 4. PSA _Sonography_ 1. Quantification of residual urine after micturition 2. Renal ultrasound 3. Quantification of leaked urine: pad test _Additional testing_ 1. Micturition cysto-urethrogram 2. Urodynamic examination to measure bladder pressure 1. Cystoscopy – to rule out tumours 2. MRI to identify pelvic floor defects

Answer 59

_Physical measures to prevent leakage_ * Absorbent products * Catheterisation * Urethral occlusion * Pessaries and penile compression devices _Lifestyle changes_ * Weight loss * Dietary changes (e.g. decrease consumption of alcohol, caffeine, carbonated drinks) * Smoking cessation _Behavioural therapies and exercise_ * Bladder training * Kegal exercises * Vaginal weighted cones * Biofeedback _Medical treatment (urge incontinence)_ 1. Anticholinergics (oxybutynin) – competitive blockage of acetylcholine at the muscuranic acetylcholine receptors -parasympathetic receptors - parasympathetic effect is impaired - decreased overactivity of the detrusor muscle - reduced voiding 2. Alternatives * Alpha blockers e.g. tamsulosin – useful in BPH * Additional spasmolytic agents e.g. scopolamine – reduce bladder spasms * Tricyclic antidepressants (anticholinergic) e.g. imipramine _Topical vaginal oestrogen in postmenopausal patients with vaginal atrophy_ _For BPH_ 1. Finasteride – Alpha-reductase inhibitor, which inhibits the production of dihydrotestosterone from testosterone. Medication may stop prostate growing. 2. Alpha-blockers e.g. prazosin – relax smooth muscle of the prostate and bladder neck, which allows urine to flow more easily. Provide immediate benefits 3. Transurethral prostate resection

Answer 60

Three major histological changes occur 1. Glomerulosclerosis 2. Glomerular basement membrane thickening 3. Mesangial expansion

Answer 61

1. Azotaemia/ uraemia (elevated serum urea/ creatinine) 2. Oliguria 3. Haematuria (macroscopic usually) 4. Mild to moderate proteinuria 5. Hypertension

Answer 62

1. Post infectious glomerulonephritis 2. IgA Nephropathy 3. Mebrano-proliferative glomerulonephritis

Answer 63

1. Proteinuria 2. Hypoalbuminaemia 3. Peripheral oedema 4. Hyperlipidaemia 5. Lipiduria

Answer 64

1. minimial change disease 2. membranous nephropathy 3. focal segmental glomerulosclerosis