GU Flashcards

Question

Which criteria is used for AKI

Answer 1

RIFLE criteria + KDIGO system

Answer 2

Tall tented T wave Wide QRS Absent P waves

Answer 3

* Investigations are aimed at making the diagnosis, assessing the severity of the AKI and finding an underlying cause.* U&Es: K+, H+, Urea, Creatinine FBCs + CRP: Sign of infection VBG: Metabolic acidosis **Renal biopsy - to confirm intrarenal cause / USS - to confirm pot-renal cause**

Answer 4

_Treat complications_: **Hyperkalaemia** —> stabilise cardiac membrane - **Calcium gluconate** Fluid overload - **Furosemide** Metabolic acidosis - **Sodium bicarbonate** _Treat underlying cause_ Discontinue nephrotoxic drugs _Rehydrate Px - IV fluids_ _Renal replacement therapy_ - last resort: Haemo-dialysis: **A FUK** Acidosis Fluid overload Uraemic - present as Encephalopathy / pericarditis HyperKalaemia

Answer 5

Progressive deterioration in renal function **eGFR <60 for ≥ 3months** Normally at 120

Answer 6

**Diabetes mellitus HTN** ^Most common Increased age Glomerulonephritis Nephrotoxic drugs (NSAIDS, lithium)

Answer 7

Stage of renal failure… Based on the eGFR mL/min/1.73m2 G1. 90+ G2. 60-89 G3. A) 45-59 B) 30-44 G4. 15-29 G5. < 15 (known as “end-stage renal failure”)

Answer 8

Early on Px = asymptomatic as theres still lots of nephrons *Sx start due to substance accumulation + renal damage* (e.g diabetic nephropathy) Sx: Lethargy Pruritis —> uraemic Nausea *Frothy urine* swollen ankle —> fluid overload Hypertension

Answer 9

Renal function based on the albumin:creatinine ratio: A1 = < 3mg/mmol A2 = 3 – 30mg/mmol A3 = > 30mg/mmol * The patient does not have CKD if they have a score of A1 combined with G1 or G2*

Answer 10

Progressive reduction in kidney function leading to mesangial scarring (support tissue in glomerulus) *The most common cause of CKD is **diabetes**, excess glucose in the blood starts sticking to proteins in the blood — non-enzymatic glycation. Affects the **efferent arteriole** and causes it to get **stiff and more narrow** increases pressure —> **hyperfiltration**. the supportive **mesangial cells** secrete more and more structural matrix **expanding the size** of the glomerulus. **Diminishes** the nephron’s ability to **filter** the blood —> chronic kidney disease.* * In hypertension, the walls of arteries supplying kidney **thicken** in order to withstand the pressure —> **narrow lumen**. A narrow lumen means **less blood and oxygen** gets delivered to the kidney, resulting in **ischemic injury** to the nephron’s glomerulus. Macrophages and foam cells called slip into the damage glomerulus and start **secreting growth factors** like Transforming Growth Factor ß1 **(TGF-ß1)**. These growth factors cause the **mesangial cells to regress** back to their more immature stem cell state known as **mesangioblasts** and secrete extracellular structural matrix. This excessive extracellular matrix —> glomerulosclerosis, hardening and scarr, and diminishes the nephron’s ability to filter the blood*

Answer 11

Anaemia —> reduced EPO, reduced RBC Osteodystrophy —> reduced Vit D activation Neuropathy + encephalopathy —> hyperuraemia Cardiovascular disease e.g pericarditis / arrhythmias

Answer 12

Estimated glomerular filtration rate **(eGFR)** U&E blood test. Two tests are required 3 months apart to confirm a diagnosis of chronic kidney disease. - use its **staging —> G score** **Proteinuria** can be checked using a **urine albumin:creatinine ratio (ACR)**. A result of **≥ 3mg/mmol** is significant. - use **A -score** Haematuria can be checked using a **urine dipstick**. A significant result is 1+ of blood. Haematuria should prompt investigation for malignancy (i.e. bladder cancer). **Renal ultrasound** can be used to investigate patients with accelerated CKD, haematuria, family history of polycystic kidney disease or evidence of obstruction.

Answer 13

No cure so Tx complication: Anaemia - Fe + EPO Osteadystrophy - Vit D (calcitriol) / bisphosphonates CVD - ACEi (1st line - exacerbational - cause of AKI but used for HTN) Oedema - diuretics For stage 5 (ESRF) - dialysis (renal replacement therapy) / renal transplant (curative)

Answer 14

hyperplasia of the **stromal and epithelial** cells of the prostate. It usually presents with **lower urinary tract symptoms.**

Answer 15

IPSS International prostate symptoms score

Answer 16

BPH usually non malignant proliferation of inner **transitional zone** of prostate Prostate cancer usually proliferation of outer **peripheral** zone

Answer 17

Increased age Male Afrocarribean Fx Diabetes Obesity Castration - protective

Answer 18

Hyperplasia of both glandular epithelial cells and stromal (connective tissue) cells. With age, there is an **increase in activity** of **5-alpha reductase** —> Increases **dihydrotestosterone** (DHT) and oestrogen. DHT acts on **androgen receptors** within the prostate **causing hyperplasia** BPH predominantly affects the **peri-urethral region** of the prostate called the **transition zone**, resulting in **compression of the prostatic urethra**. **Prostate cancer** usually occurs in the **peripheral zone.** Anatomically, the **median and lateral lobes** are usually **enlarged.**

Answer 19

**LUTS** —> more so *voiding Sx* _Storage_ - frequency, urgency, nocturia, incontinence _Voiding_ - weak stream, hesitancy, terminal dribbling, dysuria Lower Abdominal pain - acute urinary retention **Signs** Smooth, enlarged, and non-tender prostate Lower abdominal tenderness and palpable bladder

Answer 20

**Digital rectal exam** *Smooth, enlarged prostate* **Prostate-specific Antigen (PSA)** *May be raise - more so in cancer though* - unreliable **IPSS**

Answer 21

_Lifestyle modification_ decrease caffeine _Drugs_ **alpha-1 blocker (tamsulosin)** - 1st line *Relaxed SMC around bladder neck* **5-alpha reductase (finasteride)** - 2nd line *Reduces testosterone conversion —> reduces prostate size* _Surgery_ *Last resort* **TURP - transurethral resection of prostate**

Answer 22

Retrograde ejaculation

Answer 23

**Adenocarcinoma** affecting proximal convoluted tubule epithelium *Remember adenocarcinoma = malignant glandular epithelial neoplasm*

Answer 24

Renal cell carcinoma

Answer 25

Clear cell carcinoma Papillary carcinoma Chromophobe

Answer 26

Majority = **sporadic** Some are hereditary Deletion in the **VHL tumour suppressor gene** (Von Hippel Lindau) —> causes increased IGF-1 —> increased cell growth…

Answer 27

Age Male Von hipped lindau disease Haemodialysis

Answer 28

_Remember classic triad for RCC_ **Haematuria Flank pain Palpable mass** _**Left sided varicocele**_ *Left testicular vein drains into the **left renal vein**; a left RCC can invade the renal vein causing **backpressure** and varicocele formation **Right** testicular vein drains **directly into the IVC**, therefore a right RCC does not cause a varicocele* _Other Sx related to cancer (constitutional Sx)_ Weight loss Fatigue

Answer 29

EPO —> **polycythaemia** Renin —> **hypertension** PTHrP / bony metastases —> **hypercalcaemia**

Answer 30

1st line - **USS** Gold standard - **CT Chest / Abdo / Pelvis** (more sensitive) Could do urinalysis *(haematuria)* / FBC *(anaemia of chronic disease or polycythaemia)* Staging - **Robson staging 1 - 4**

Answer 31

**Nephrectomy (partial / radical)** Could also do; *Radiofrequency ablation*

Answer 32

Renal mesenchymal stem cell tumour **seen in children** (< 3y/o) AKA **nephroblastoma**

Answer 33

2 types… Urothelial / Non-rothelial _Urothelial_: **Transitional cell carcinoma** of bladder —> most common (90%) _Non-urothelial_: **Squamous cell carcinoma** (7%)—> higher in Px with *schistosomiasis* Adenocarcinoma —> very rare

Answer 34

Increased age Male **Smoking** _Occupational exposure:_ **Aromatic amine** —> textiles, dye, rubber, paints - Transitional cell carcinoma *Schistosomiasis / areas with high prevalence (Egypt)* - squamous cell carcinoma

Answer 35

**Painless haematuria** (macro / microscopic) **Dysuria** _Constitutional Sx:) Weight loss Fatigue

Answer 36

**Flexible cystoscopy** *+ biopsy* - gold standard If if high risk +/ suspected *muscle invasion* - CT abdo / pelvis

Answer 37

_Medical_ Chemo / radiotherapy _Surgical:_ **TURBT** - transurethral resection of bladder tumour Radical cystectomy - last resort

Answer 38

Adenocarcinoma of the posterior **peripheral** prostate *Malignant neoplasm of glandular epithelium*

Answer 39

Genetic - BRCA 1 / BRCA 2 *(for breast cancer too)* // HOXB13 Increased age FHx Afrocaribbean ethnicity

Answer 40

LUTS *(like BPH)* but with **systemic cancer Sx** (weight loss, fatigue) ± **Bone pain** (lumbar) - typically metastasise in bone (*sclerotic lesions*), liver, lung, brain.

Answer 41

Digital rectal exam - **Asymmetrical, hard, nodular prostate** Increased **PSA** **Multiparametric MRI** - 1st line **Transrectal USS** *+ biopsy* = gold standard Gleason grading score

Answer 42

**Gleason grading score** (out of 5; done twice) - based off biopsy Low grade: ≤6 Intermediate: 7 High grade: 8-10

Answer 43

_Local_ **Prostatectomy** _Metastatic_ **Hormone therapy** (because this is the most hormone sensitive cancer) *Bilateral Orchidectomy* - best GnRH agonist (Goserelin) **Radio/Chemotherapy**

Answer 44

Androgen-dependent, meaning they rely on androgen hormones (e.g., testosterone) to grow. Decrease testosterone —> decrease cancer growth

Answer 45

GnRH agonist **Weird** - agonist for GnRH increases LH + FSH … BUT… results in **exogenous suppression of HPG axis (*hypothalamic pituitary gonadal*)** - so reduced hormones reduces prostate cancer growth

Answer 46

Testicular cancer

Answer 47

_Germ cell (90%)_ **Seminoma (most common) Teratoma** _Non-germ cell (<10%)_ Leydig Sertoli Sarcoma

Answer 48

**Undescended testes** - Cryptorchidism Infertility FHx

Answer 49

Painless lump in testicle That Does not **transilluminate** May show signs of metastases: cough/sob (lung) / bone pain (bone)

Answer 50

Urgent **doppler USS testes** - 1st line + diagnostic Tumour markers: ß-hCG - raised in seminoma AFP - raised in teratoma LDH - raised non-specifically in tumours Chest X-ray for metastasis

Answer 51

Radical orchidectomy (1st line) Adjuvant: chemo/radiotherapy

Answer 52

BPH Stones

Answer 53

Obstruction —> urine retention + increased KUB pressure —> causes refluxing/backlogged urine in renal pelvis —> leading to **HYDRONEPHROSIS** (*dilation renal pelvis; more prone to infection*)

Answer 54

Upper UTIs: pyelonephritis Lower UTIs: cystitis, Prostatitis, urethritis, epididymo-orchiditis

Answer 55

Upper UTIs: kidneys Lower UTIs: bladder and below

Answer 56

**KEEPS** Klebsiella pneumonia E.coli - *most common* Enterobacter Proteus mirabilis Staphylococcus saprophyticus

Answer 57

UPEC UroPathogenic **E.Coli**

Answer 58

Women Shorter urethra so closer to anus + easier for bacteria to colonise

Answer 59

1st line: **Urine dipstick** *+ve leukocytes +ve nitrites (bacteria breakdown nitrates—>nitrites) - can consider uti with just +ve nitrites; not just +ve leukocytes though ± Haematuria* **^shows uti likely** Gold standard: **midstream MC & S** (*microscopy, culture, sensitivity*) **^confirms uti + ID’s pathogen**

Answer 60

Infection of renal parenchyma + upper ureter. Ascending transurethral spread

Answer 61

UPEC - most commonly Any of the KEEPS: Klebsiella E. coli Enterobacter Proteus mirabilis Staphylococcus saprophyticus

Answer 62

Urine stasis - renal stones Young women <35 Catheters Pregnancy Immunocompromised

Answer 63

_Learn triad differentiating it from cystitis_ **Fever, Loin pain, N&Vomiting** ± Pyuria (*pus in urine*)

Answer 64

**_Same for all UTIs_** 1st line: urine dipstick *+ve leukocytes +ve nitrites (bacteria breakdown nitrates—>nitrites) - can consider uti with just +ve nitrites; not just +ve leukocytes though ± Haematuria* **^shows uti likely** Gold standard: **midstream MC & S** (*microscopy, culture, sensitivity*) **^confirms uti + ID’s pathogen** **_Do Ix for renal stones in case_**

Answer 65

Paracetamol; analgesia + ABx: **Ciprofloxacin or Co-amoxiclav** **Cephalexin; if pregnant**

Answer 66

Infection of the lower urinary tract; affecting bladder

Answer 67

Women Post-menopause Catheter Bladder lining damage

Answer 68

Increased frequency, urgency Dysuria Nocturia Suprapubic tenderness Confusion / delirium esp. in adults

Answer 69

Same for all UTIs 1st line: urine dipstick *+ve leukocytes +ve nitrites (bacteria breakdown nitrates—>nitrites) - can consider uti with just +ve nitrites; not just +ve leukocytes though ± Haematuria* **^shows uti likely** Gold standard: **midstream MC & S** (*microscopy, culture, sensitivity*) **^confirms uti + ID’s pathogen**

Answer 70

ABx Trimethoprim / Nitrofurantoin Amoxicillin if pregnant

Answer 71

Inflammation of the urethra ± infection Most commonly a **sexually acquired condition**

Answer 72

**_Infective has 2 types:_** _Gonococcal_ (less common) - Neisseria Gonorrhoea _Non-Gonococcal_ (more common) - Chlamydia Trachomitis **_non-infective:_** Trauma

Answer 73

Obligate intracellular gram -ve aerobic bacillus

Answer 74

Gram -ve diplococcus

Answer 75

Neisseria gonorrhoea Chlamydia trachomatis

Answer 76

Unprotected sex Multiple sex partners

Answer 77

Dysuria ± urethral discharge (blood/pus) Urethral pain

Answer 78

**NAAT** - nucleic acid amplification test —> detects STIs (Neisseria / chlamydia) **Urine dipstick** (+ve if infectious UTI) + **MC + S** (will detect pathogen ID if UTI) : gram -ve diplococcus = gonorrhoea

Answer 79

Neisseria G: **IM Ceftriaxone + Azithromycin** Chlamydia T: **Azithromycin ( / doxycycline)**

Answer 80

Reactive arthritis *Cant see (conjunctivitis) Cant pee (**urethritis**) Cant climb a tree (arthritis)*

Answer 81

**Inflammation of epididymis, extending to testes** *At the back of each testicle is the epididymis. Sperm are released from the testicle, into the head of the epididymis, connected at the top of the testicle. The sperm travel through the head, then body, then tail of the epididymis. Sperm mature and are stored in the epididymis. The epididymis drains into the vas deferens.* **Usually due to urethritis (STI) - more in <35y/o OR cystitis (KEEPS) extension - more in >35y/o**

Answer 82

**Usually due to urethritis (STI) - *more in <35y/o* OR Cystitis (KEEPS - Enteric bacteria) extension - *more in >35y/o* OR Mumps (viral)**

Answer 83

Males - infection of the epididymis + testes

Answer 84

Unilateral, tender, red swollen testicle Pain relieved by elevating testis (**+ve Prehn’s sign**) Cremasteric reflex intact LUTS

Answer 85

Testicular torsion - *Acute presentation like epididymo-orchitis with testicular pain but higher change of testes death so Tx like torsion until proven otherwise* (+ additional Sx: N+V, cryptorchidism / bell clapper)

Answer 86

NAAT - for NG / CT Urine dipstick Urine MC+S

Answer 87

_If STI:_ Neisseria G—>** IM Ceftriaxone + Azithromycin** Chlamydia T—> **Azithromycin / doxycycline** _If UTI_ **Ciprofloxacin** - quinolone = powerful broad-spectrum antibiotics for gram -ve esp **Co-amoxiclav**

Answer 88

_NephrOtic_ *Pr**o**teinurea* Hyp**o**albuminemia Oedema ± hypertension _Nephritic_ *Haematuria* Oliguria Oedema

Answer 89

1º - Minimal change disease (MC in children) Focal segmented glomerulosclerosis (MC in African / Hispanic descent) Membranous nephropathy (adults; causcasian) 2º - Diabetic nephropathy Amyloidsis

Answer 90

**Proteinuria** - _Frothy urine_ Hypoalbuminaemia Oedema Hyperlipidaemia

Answer 91

**_Take kidney biopsy_** Minimal ∆ disease *Light microscopy - NO CHANGE E- microscope - podocyte effecement + fusion* Focal segmental glomerulosclerosis *Light microscopy - segmental sclerosis; less than 50% glomeruli affected though* Membranous nephropathy *Light microscopy - thickened glomerulus basement membrane E- microscope - subpodocyte immune complex deposition, spike and dome appearance*

Answer 92

Minimal ∆ disease - corticosteroids (12 weeks) Focal segmental glomerulosclerosis + membranous nephropathy respond less well to steroids

Answer 93

When **glomeruli** are **damaged** becoming more **_permeable_** ~ T cells in the blood, releasing cytokines: glomerular-permeability factor (**GPF**), that specifically damages the foot processes of the **podocytes**, making them flatten out (**effacement**) Allows proteins to be filtered through into the urine (proteinuria) *Main protein lost ~ Albumin; leads to less in blood (hypoalbuinaemia) ~ This then leads to peripheral and peri-orbital oedema Because there’s reduced oncotic pressure. Px becomes hypercoaguable too ~ due to loss of anti-thrombin III protein ~ so increased thrombosis formation. Loss of immunoglobulins increases risk of infection*

Answer 94

≥ 3.5g per day

Answer 95

**Inflammation** that damages **glomerular basement membrane** *This leads to haematuria and RBC casts in urine ~ can then lead to renal failure; presenting with … Oliguria Arterial hypertension Peripheral and peri-orbital oedema.*

Answer 96

_Type III hypersensitivity reaction_ IgA nephropathy (Berger’s disease) - most common cause Post Strep. Glomerulonephritis SLE Haemolytic uraemic syndrome _Type II hypersensitivity_ Goodpasture’s syndrome

Answer 97

**Visible haematuria** (blackish / coke-cola like) HTN Oliguria Usually seen 2 weeks after Px had pharyngitis from group A/B haemolytic streptococcus ~ strep. Pyogenes **_investigation & Dx:_** Light microscope - **hyper cellular** glomeruli E- microscope - subendothelial **humps** Immunofluorescence - **starry sky** ~ deposition of IgG, IgA & C3 in G. Basement membrane **_Tx:_** Self-resolves in children In adults could lead to

Answer 98

**Visible haematuria** (blackish / coke-cola like) HTN Oliguria Px presents 1-2n days after **tonsillitis viral infection** / gastroenteritis viral infection *~ more commonly seen in Asian populations ~associated with HIV* **_Dx:_** Immunofluoresence - IgA complex deposition Light microscopy shows mesangial hypercellularity **_Tx:_** Non-curative BP control - ACEi (1st line control)

Answer 99

2º to SLE (ANA deposits in endothelium) Cause of nephritic syndrome +ve ANA +ve Anti-dsDNA

Answer 100

Corticosteroids + immunosuppressants

Answer 101

Anti-Glomerular basement membrane (GBM) antibody disease Autoimmune disease whereby circulating antibodies target the lungs and kidneys, causing pulmonary haemorrhage and glomerulonephritis.

Answer 102

Corticosteroids - prednisolone + plasma exchange

Answer 103

RPGN Rapidly progressing glomerulonephritis

Answer 104

Progress to end stage renal failure v.fast **Inflammatory crescents** in bowman’s space

Answer 105

Yes true Autoimmune vasculitis is P-ANCA positive

Answer 106

Cyst formation throughout the renal parenchyma - bilateral enlargement + damage

Answer 107

Familial inherited: Autosomal recessive - **much less common** Presents in **neonates** and is usually picked up on antenatal ultrasound scans. It is the result of a mutation in the polycystic kidney and hepatic disease 1 (**PKHD1**) gene on chromosome 6. Autosomal dominant - **most common** Presents more in males; Px at 20-30y/o Mutation in PKHD1 (85%) / PKHD 2 (15%)

Answer 108

PKHD 1 / 2 genes encode for polycystin (Ca2+ channels) in the cilia of nephron… When filtrate passes cilia move and open Polycystin; influx of Ca2+ inhibits excessive growth… so…. When theres a mutation, you get decreased ca2+ influx and cilia grow excessively

Answer 109

Bilateral flank / back or abdominal pain ± hypertension & haematuria (I.e. chronic loin pain) Extra-renal cysts: esp in circle of Willis (berry aneurysm; if ruptured becomes subarachnoid haemorrhage) / prostatic cysts

Answer 110

Kidney **uss** *Enlarged bilateral kidneys with multiple cysts* Genetic testing

Answer 111

Non curative **Tolvaptan** - vasopressin receptor antagonist Antihypertensives for hypertension. Analgesia for renal colic related to stones or cysts. Antibiotics for infection. Drainage of infected cysts may be required.

Answer 112

**Scrotal mass —> cancer till proved otherwise** Epidyidymal cyst Hydrocele Varicocele Testicular torsion

Answer 113

Extra testicular cysts (above + behind testis) that will transilluminate Dx: **USS scrotum**

Answer 114

Fluid collection in tunica vaginalis - cyst that testicle sites within that will transilluminate Dx: USS scrotum

Answer 115

**Bag of warms** (on LHS mostly) Distended Pampiniform plexus because of **increased left renal vein pressure causing reflux** - typically painless. Dx: clinical

Answer 116

Spermatic cord twists on itself; occlusion of testicular artery causes ischaemia —> gangrene of testis if not tx **Surgical emergency**

Answer 117

Bell clapper deformity **- horizontal lie of testes**

Answer 118

Severe unitesticular pain (hurts to walk) Abdominal pain; N&V **-VE PREHNS SIGNS** - lifting testis doesn’t alleviate the pain No cremasteric reflex *^Both seen in epididymo-orchitis - DDx^*

Answer 119

**surgical exploration** - if high risk of torsion. USS to check testicular blood flow Could later do a urinalysis - to see if sign of epididymo-orchitis

Answer 120

Urgent surgery within 6hrs (for >90% success) - all cases require bilateral orchiplexy (fixing of testes to scrotal sac to overcome bell clapper deformity; if not viable, do orchidectomy)

GU Flashcards

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