GU Flashcards

Question

What are the NICE criteria for diagnosing an AKI?

Answer 1

Rise in creatinine of ≥ 25 micromol/L in 48 hours Rise in creatinine of ≥ 50% in 7 days Urine output of < 0.5ml/kg/hour for > 6 hours

Answer 2

- Hypoperfusion due to hypovolaemia. This causes ischaemia of the the renal parenchyma. Prolonged ischaemia can lead to intrinsic damage - Heart failure - Dehydration - Hypotension

Answer 3

- **Vascular**: can be due to atherosclerotic disease and dissections. Also can be caused by renal artery stenosis - **Glomerular**: may be primary or secondary. Can lead to nephritic or nephrotic syndrome - **Tubulo-intestinal**: usually due to acute tubular necrosis or acute interstitial nephritis that can occur secondary to medications (e.g. NSAIDs, ACE inhibitors, PPI’s, penicillin's) and infections.

Answer 4

Intrinsic disease in the kidney is leading to reduced filtration of blood. It may be due to: Glomerulonephritis Interstitial nephritis Acute tubular necrosis

Answer 5

- Obstruction- due to urinary stones, malignancy or bladder neck obstruction e.g., benign prostate hyperplasia

Answer 6

- Chronic kidney disease - Heart failure - Diabetes - Liver disease - Older age (above 65 years) - Cognitive impairment - Nephrotoxic medications such as NSAIDS and ACE inhibitors - Use of a contrast medium such as during CT scans

Answer 7

- Reduced capillary refill time - Reduced skin turgor - Thirst - Dizziness - Tachycardia - Hypotension - Reduced urine output

Answer 8

- Arterial hypertension and peripheral oedema

Answer 9

- Heavy proteinuria - Hypoalbuminemia - Oedema

Answer 10

- Haematuria - Proteinuria - Oliguria - Hypertension

Answer 11

- Arthralgia (joint pain) - Rashes - Fever

Answer 12

**Urinalysis** for protein, blood, leucocytes, nitrites and glucose. - Leucocytes and nitrites suggest infection - Protein and blood suggest acute nephritis (but can be positive in infection) - Glucose suggests diabetes

Answer 13

- Vasculitis screen (e.g. ANCA, ANA) - Hepatitis screen - Blood gas - LFT

Answer 14

- Regular monitoring - Cease nephrotoxic drugs - IV fluids for hypovolaemia - Relieve obstruction

Answer 15

Hyperkalaemia as potassium is not being removed from the blood. Treat first with calcium gluconate to protect the heart then use insulin and dextrose. Salbutamol can also be used to drive potassium into cells

Answer 16

- Fluid overload which can cause heart failure and oedema - Metabolic acidosis - Uraemia can lead to **Encephalopathy** or **Pericarditis**

Answer 17

RENAL DRS26 R- Record baseline creatinine E- Exclude obstruction N- Nephrotoxic drugs stopped A- Asses fluid status L- Losses+/- D- Dipstick R- review medications S- Screen 26- Creatinine rise for AKI diagnosis of higher than 26

Answer 18

A progressive deterioration in renal function over at least 3 months

Answer 19

- Hypertension (second most common) - Diabetes (most common)

Answer 20

- Systemic disease e.g., Rheumatoid arthritis - Infections (HIV) - Medications, PPI, ACE inhibitor, NSAIDs, lithium - Toxins (in smoking) - Age-related decline - Glomerulonephritis - Polycystic kidney disease

Answer 21

- Walls of arteries thicken in order to withstand higher pressure resulting in a narrow lumen - This means less blood is delivered to the kidney resulting in ischaemic injury - This causes the infiltration of immune cells that secrete **TGF-b1**. This growth factor transforms mesangial cells back to more immature stem ell which diminishes their ability to filter the blood

Answer 22

- Excess glucose in the blood starts sticking to proteins (non-enzymatic glycation). - This particularly affects the efferent arteriole and causes it to get stiff and narrow. This creates an obstruction and makes it difficult for the blood to leave the glomerulus. - Over many years this process dimishes the nephrons ability to filter blood

Answer 23

- Hypertension - Fluid overload - Uraemic sallow: yellow or pale brown colour of skin - Uraemic frost: urea crystals can deposit in the skin - Pallor - Evidence of underlying cause

Answer 24

- Pruritis - Loss of appetite - Nausea - Oedema - Muscle cramps

Answer 25

- **Estimated GFR**: can be checked using U&E blood test. **Two tests required 3 months apart** - **Proteinuria**: can be checked using a **urine albumin:creatinine ratio**. A result of greater than 3mg/mmol is significant - **Haematuria**: can be checked using a **urine dipstick** - **Renal ultrasound**

Answer 26

G score and A score

Answer 27

G score is based of eGFR G1: eGFR>90 G2: eGFR: 60-89 G3a: eGFR: 45-59 G3b: eGFR: 30-44 G4: eGFR: 15-29 G5: eGFR<15 known as end-stage renal failure

Answer 28

Based off the albumin:creatinine ratio: A1: <3 A2: 3-30 A3: >30

Answer 29

A1 combined with G1 or G2

Answer 30

Slowing the progression of the disease Optimise diabetic control Optimise hypertensive control Treat glomerulonephritis Reducing the risk of complications Exercise, maintain a healthy weight and stop smoking Special dietary advice about phosphate, sodium, potassium and water intake Offer atorvastatin 20mg for primary prevention of cardiovascular disease

Answer 31

- Renal bone disease - Anaemia - Cardiovascular- hypertension, hypercholesterolemia , heart failure due to fluid overload and anaemia

Answer 32

- There is high serum phosphate as there is reduced phosphate excretion. There is also a low amount of active vitamin D as it is activated in the kidneys - Therefore there is secondary hyperparathyroidism as a result which leads to an increase in osteoclast activity

Answer 33

- Osteomalacia: occurs due to increased turnover of bones without calcium supply - Osteosclerosis: osteoblasts respond to increase osteoclast activity and make new tissue but it is poorly mineralised due to the lack of calcium - Osteoporosis Osteomalacia (softening of bones) Osteosclerosis (hardening of bones) Osteoporosis (brittle bones)

Answer 34

- Supplements of active forms of Vit D. (alfacalcidol and calcitriol) - Low phosphate diet - Bisphosphonates can be used to treat osteoporosis

Answer 35

- Erythropoietin is used to stimulate the production of RBC. In CKD there is reduced secretion of erythropoietin. - Anaemia caused by this can be treated by giving exogenous erythropoietin. **Blood transfusions should be limited as they can sensitise the immune system (“allosensitisation”) so that transplanted organs are more likely to be rejected**

Answer 36

- Upper urinary tract infection: acute inflammation of the renal pelvis (join between kidney and ureter) and parenchyma

Answer 37

- Affects females under 35 - Unusual in men

Answer 38

The urethra is much shorter in women so it makes it easier for bacteria to reach the bladder and kidneys

Answer 39

Can be spread via ascending infections or hematogenous spread Common species include: - E.coli (most common) - Klebsiella - Enterobacter - Staphylococcus

Answer 40

- Sexual intercourse - Catheter - Diabetes - Pregnancy - Renal stones

Answer 41

- Most often caused by ascending infection. Bacteria will start by colonising the urethra and bladder and make their way up to the kidney - Risk of lower UTI transferring to an upper UTI is increased by **vesicoureteral reflux** where urine is allowed to move back up the urinary tract due to a failure in the vesicoureteral orifice

Answer 42

- Tender loin on examination - Pain on palpation of renal angle Symptoms will often be present on both sides as both kidneys are affected

Answer 43

- Fever - Loin to groin pain - Dysuria (painful to piss) and urinary frequency - Haematuria - Cloudy foul smelling urine

Answer 44

- Fever - Loin/back pain - Nausea/vomiting - Renal angle tenderness

Answer 45

- Nitrites as gram negative bacteria such as E.coli and Klebsiella breakdown nitrates into nitrites - Leukocyte esterase on urine dipstick indicates an infection Nitrites are better indication. But leukocyte esterase plus haematuria indicates infection

Answer 46

- Mid-stream urine MCS- white blood cell in the urine

Answer 47

- **Broad spectrum antibiotics (e.g. co-amoxiclav)** until culture and sensitivities are available - **Hydration**

Answer 48

- Renal abscess - Recurrent infections - Chronic pyelonephritis- which can leads to the scaring of renal tissue which can lead to AKI and CKD - Papillary necrosis

Answer 49

A lower UTI that involves the bladder

Answer 50

- Post-menopause the absence of oestrogen increases the risk - Sexual intercourse - Diabetes - Poor bladder emptying- allows the bacteria to adhere and colonise the bladder

Answer 51

- An inflamed bladder is usually the result of a bacterial infection, but also can result from fungal infections, chemical irritants, foreign bodies like kidney stones, as well as trauma. - Lower UTIs are almost always caused by an ascending infection, where bacteria typically moves from the rectal area to the urethra and then migrate up the urethra and into the bladder. - On rare occasions, a descending infection can happen as well where bacteria starts in the blood or lymph and then goes to the kidney and makes its way down to the bladder and urethra.

Answer 52

Suprapubic tenderness

Answer 53

- Dysuria - Frequency - Urgency - Nocturia - changes in appearance - Suprapubic discomfort

Answer 54

- **Mid-stream urine microscopy, culture and sensitivity (MC&S)**: - The most specific and sensitive test; bacteria, WBCs, +/- RBCs expected

Answer 55

Treatment may be delayed if symptoms are mild - First line would be 3 days of **nitrofurantoin avoided in patients with CKD** or **trimethoprim** - Second line Antibiotic course for 3 days -**pivmacillinam or fosfomycin single-dose sachet**

Answer 56

- **First line:** Antibiotic course for 7 days - nitrofurantoin avoid in third trimester. Trimethoprim is avoided in first trimester as it increases the risk of neural tube defects - **Second line:** Antibiotic course for 7 days - amoxicillin or cefalexin

Answer 57

- **Pre-term delivery** - **Low-birthweight**

Answer 58

A severe infection involving the prostate that may cause significant systemic upset

Answer 59

- E.coli most common - STI's - Catheter - Disseminated infections- secondary to S.aureus due to metastatic spread

Answer 60

- Tender, hot swollen prostate (on digital rectal exam) - Palpable bladder - Tachycardia - Pyrexia

Answer 61

- Dysuria - Frequency and retention - Straining - Back pain - Fever - Perineal, rectal or pelvic pain

Answer 62

- Digital rectal exam - Urine dipstick - MSU, semen and blood culture

Answer 63

First line- Oral ciprofloxacin or ofloxacin Second line- Oral levofloxacin or co-trimoxazole

Answer 64

- **Acute urinary retention** - **Epididymitis** - **Chronic prostatitis** - **Prostatic abscess**

Answer 65

The four glass (or two glass) test: pre- and post- prostatic massage. - **Voided bladder 1 (VB1):** first 10ml of urine passed, represents urethra. - **Voided bladder 2 (VB2):** second 10ml of urine passed, represents bladder. - **Expressed prostatic secretions (EPS):** first 10ml of urine passed, represents urethra. - **Voided bladder 3 (VB3):** first 10ml of urine passed, after EPS. The two glass test, just involving EPS and VB3 is commonly used. **I:** Acute bacterial prostatitis (ABP) **II:** Chronic bacterial prostatitis (CBP) **III:** Chronic pelvic pain syndrome (CPPS) **IIIA:** Inflammatory CPPS (leucocytes in semen/EPS/VB3) **IIIB:** Non-inflammatory CPPS (no leucocytes in semen/EPS/VB3) **IV:** Asymptomatic inflammatory prostatitis (histological prostatitis)

Answer 66

Urethral inflammation due to infectious or non-infectious causes. It is primarily a sexually acquired disease!

Answer 67

Chlamydia (louis has this) this is slander and i do not stand for it

Answer 68

Gonococcal and non-gonococcal

Answer 69

Neisseria gonorrhea

Answer 70

- Chlamydia trachomatis (most common accounts for up to 50%) - Mycoplasma genitalium

Answer 71

- Trichomonas vaginalis - Yeasts - Herpes simplex virus - Adenovirus - Other bacteria such as streptococci, mycobacteria, or anaerobes.

Answer 72

- Trauma - Irritation - Urinary calculi (in english we call these kidney stones why use silly words)

Answer 73

- Male to male sex - Unprotected sex - multiple sexual partners

Answer 74

- Urethral discharge - Urethral irritation/itching - Dysuria - Penile discomfort - Skin lesions

Answer 75

- Nucleic acid amplification test - Microscopy of gram-stained smears of genital secretions - Culture of urethral discharge - Urine dipstick to rule out UTI

Answer 76

- Oral **azithromycin** or oral **doxycycline** - If pregnant give erythromycin

Answer 77

- IM ceftriaxone with oral azithromycin Also partner notification and contact tracing

Answer 78

- **Reactive arthritis** - **Gonococcal conjunctivitis** - **Periurethral abscess** - **Urethral stricture or fistula** - **Epididymitis** - **Prostatitis** - **Penile lymphangitis**

Answer 79

Inflammation of the epididymis (epididymitis) and inflammation of the testicle (orchitis)

Answer 80

STIs e.g., Chlamydia trachomatis, Neisseria Gonorrhoea and mycoplasma genitalium

Answer 81

- E.coli and proteus sp. - Can also be caused by TB and viral infections such as mumps

Answer 82

- Tenderness and palpable swelling - **Prehn's sign positive**: pain is relieved with lifting the testicle, negative in testicular torsion - **Cremasteric reflex preserved**- unlike testicular torsion

Answer 83

- **Unilateral tender, red, and swollen testicle** - Pain develops over a few days - **Lower urinary tract symptoms e.g. dysuria** - **Urethral discharge: may and or may not be present**

Answer 84

- Urinalysis - Nucleic acid amplification test (NAAT) - Swab of urethral secretions

Answer 85

- Fluoroquinolone e.g., ofloxacin or ciprofloxacin

Answer 86

- Musculoskeletal: reactive arthritis - Infective: disseminated infection secondary to gonorrhoea

Answer 87

- Musculoskeletal: reactive arthritis - Infective: disseminated infection secondary to gonorrhoea - Infertility - Urological: epidydimal obstruction and scarring secondary to poorly treated infection

Answer 88

- Nephritic syndrome or acute nephritic syndrome refers to a group of symptoms, not a diagnosis. - They fit a clinical picture of having inflammation of their kidney and it does not represent a specific diagnosis or give the underlying cause. -

Answer 89

Haematuria Oliguria Proteinuria Fluid retention

Answer 90

Refers to a group of symptoms without specifying the underlying cause. Therefore, nephrotic syndrome is not a disease, but is a way of saying “the patient has these symptoms”

Answer 91

- Peripheral oedema - Proteinuria - Serum albumin less than 25g/L - Hypercholesterolemia

Answer 92

Defined by the presence of dominant or co-dominant mesangial IgA immune deposits, often accompanied by C3 and IgG. Also called Berger's disease (poor guy had the name taken away from him for this boring one) nephritic syndrome condition

Answer 93

80% diagnosed between 16 and 35 and more common in Asian population

Answer 94

- Occurs when abnormal IgA antibodies are produced by the body usually after a respiratory or GI tract infection - This causes the body to recognise them as foreign producing IgG antibodies to target them. This immune complexes travel in the blood stream and get trapped in the kidneys

Answer 95

- They are deposited in the mesangium (tissue surrounding the Bowman's capsule). - This activates the complement pathway leading to the release of cytokines and macrophages which damage the glomerulus

Answer 96

- Haematuria - Oedema due to proteinuria - Cervical lymphadenopathy suggests recent URTI as trigger - Hypertension

Answer 97

- **Pink, red or “coke” tinged urine (haematuria)** - **Foamy urine (proteinuria)** - **Sore throat:** suggests an URTI as a recent trigger - **Loose stools and abdominal discomfort:** suggests gastroenteritis as a recent trigge

Answer 98

U&Es and urine dipstick C3 and C4- C4 will be normal where as C3 might be low

Answer 99

**Renal biopsy** - **On light microscopy**: **see mesangial proliferation**. - **On immunofluorescence:** IgA immune complexes in the mesangium - **On electron microscopy**: immune complexes are seen in the mesangium.

Answer 100

- **IgA vasculitis, also known as Henoch-Schonlein purpura**: the difference is IgA nephropathy only affects the kidneys, while IgA vasculitis can cause nephritic or nephrotic syndrome, and also presents with colicky abdominal pain, bloody stool, arthritis, and palpable skin lesions. - Management

Answer 101

- ACE inhibitor for BP - Corticosteroids - Statins - Omega-3 fatty acids

Answer 102

- **Hypertension:** due to damage to the glomerulus and its filtering function - **Acute kidney injury** - **Chronic kidney disease (CKD)** - **Rapidly progressive glomerulonephritis (RPGN)**

Answer 103

Post-streptococcal glomerulonephritis (PSGN) is usually an immunologically-mediated delayed consequence of pharyngitis or skin infections caused by **streptococcus pyogenes** Most frequently seen in children

Answer 104

- Some strep A strains carry the M-protein virulence factor which initiates a type III hypersensitivity reaction. IgG and IgM antibodies form immune complexes - These immune complexes get deposited on the basement membrane of the glomerulus which initiates an inflammatory response

Answer 105

- Haematuria - Recent strep infection

Answer 106

- **Bloods:** low levels of C3 and CH50 - **Positive streptozyme test** confirms recent group A streptococcal infection

Answer 107

- **Kidney biopsy:** isn’t always necessary, but can provide specific clues - On light microscopy: **the glomeruli are enlarged and hypercellular**. - On immunofluorescence: IgG, IgM and C3 deposits along the glomerular basement membrane and the mesangium, which create a “starry sky” appearance. - On electron microscopy: subepithelial deposits which appear as “humps”.

Answer 108

Furosemide Antibiotics

Answer 109

PSGN usually resolves on its own in children. In adults, it can sometimes lead to renal failure. Age affects prognosis!

Answer 110

Diffuse proliferative glomerulonephritis is the most common form of lupus nephritis.

Answer 111

- **Middle-aged**: peak age of onset is between 15 and 45 years old - **Female gender**: 12 times more common in females - **African and Afro-Caribbean**: more common and more severe in these patients

Answer 112

- Lupus is an autoimmune condition that affects multiple organs. It is a type III hypersensitivity reaction where immune complexes are deposited in various parts of the body - Most common site of deposition is in the **subendothelial space** of the glomerular basement membrane

Answer 113

- Haematuria - Proteinuria - Hypertension - Oedema - Lethargy - **Musculoskeletal pain and butterfly rash**

Answer 114

- **Urinalysis:** haematuria and proteinuria - **U&Es:** reduced eGFR as renal failure progresses - **Renal USS:** exclude structural pathology

Answer 115

Renal biopsy - On light microscopy: **immune complexes create an overall thickening of the capillary wall, which gives a “wire loop” appearance**. - On immunofluorescence: granular immune complexes. - On electron microscopy: sub-endothelial immune complexes

Answer 116

- Lifestyle stop smoking and exercise more Pharmacological **Corticosteroids** **Immunosuppressants** e.g., azathioprine mercaptopurine and cyclophosphamide **Hydroxychloroquine**

Answer 117

Goodpasture’s disease, also known as anti-glomerular basement membrane antibody (anti-GBM) disease, is an important cause of pulmonary-renal syndrome (Goodpasture’s syndrome).Pulmonary-renal syndrome consists of glomerulonephritis and pulmonary haemorrhage.

Answer 118

- It is caused by antibodies to the alpha-3 chain of type IV collagen (makes the basement membrane if you can remember phase 1) . - thanks tom x - Alpha-3 subtype only affects basement membrane of a few tissues particularly **Alveoli** and the **glomeruli**

Answer 119

HLA-DRB1 or DR4

Answer 120

- Reduced urine output - Haemoptysis (pulmonary haemorrhage) - Oedema

Answer 121

- Renal function tests - GOLD STANDARD- renal biopsy - anti-glomerular basement membrane (anti-GBM) antibody titre - ANCA test (50% of patients will have these antibodies as well)

Answer 122

- Oral corticosteroid - Plasmapheresis to remove the anti-GBM antibodies - Cyclophosphamide

Answer 123

It occurs when the basement membrane in the glomerulus becomes highly permeable to protein allowing them to leak from the blood into the urine.

Answer 124

Low serum albumin High urine protein count Oedema

Answer 125

- Deranged lipid profile (high levels) - as the liver increases synthesis in response to low levels of albumin - High blood pressure - Hyper-coagulability- due to loss of protein C and S in the urine

Answer 126

- Frothy urine - Oedema - Pallor

Answer 127

The most common cause in children causing over 90% of cases in children under 10. In minimal change disease, nephrotic syndrome occurs in isolation, without any clear underlying condition or pathology

Answer 128

If you spot a 2 – 5 year old child with oedema, proteinuria and low albumin, you may be asked about the underling cause. The answer is likely to be nephrotic syndrome.

Answer 129

- On light microscopy, the glomeruli look completely normal. - In some cases, there can be lipids in the proximal tubular cells. - Immunofluorescence is negative. - The only changes are seen on electron microscopy, where there’s effacement of podocyte foot processes.

Answer 130

It is the most common cause of nephrotic syndrome in individuals of African or Hispanic descent

Answer 131

- HIV - Heroin abuse - Infection - Interferon treatment

Answer 132

- On light microscopy, there’s sclerosis and hyalinosis among the glomeruli. - FSG is segmental - only a part of the glomeruli is affected - and focal - only some of the glomeruli are affected.

Answer 133

Primary FSG has an inconstant response to corticosteroids and some individuals may progress to CKD

Answer 134

- Can be primary - Or secondary to - SLE, drugs e.g. NSAIDs, gold and penicillamine, infections- particularly hep B, hep C or syphillis and solid tumours e.g. colorectal carcinoma

Answer 135

- Damage is caused by immune complexes. They are called subepithelial deposits because they build up between podocytes and glomerular basement membrane. - One major antigen that’s been identified is the **phospholipase A2 receptor or PLA2R** - In the serum of individuals with membranous nephropathy - you can find **IgG antibodies against PLA2R.**

Answer 136

**On light microscopy**: diffuse capillary and basement membrane thickening caused by immune complex deposition **On immunofluorescence**: will show immune complexes of IgG and C3 **On electron microscopy**: There will be flattening of the podocyte foot processes and subepithelial deposits. There are expansions of the basement membrane that separate around the immune complexes creating a **spike and dome pattern**

Answer 137

Three types of MPGN: they all cause proliferation of mesangial and endothelial cells in the glomerulus. Membranoproliferative glomerulonephritis is a type of glomerulonephritis caused by deposits in the kidney glomerular mesangium and basement membrane thickening, activating complement and damaging the glomeruli.

Answer 138

Most common subtype accounts for 90% of cases associated with SLE, hepatitis CLL and lymphoma - Deposits in the subendothelial space

Answer 139

- Due to persistent activation of the alternative pathway. - Low levels of circulating C3 - Associated with **factor H deficiency and lipodystrophy** - Deposits in the basement membrane

Answer 140

- **Type III MPGN**: poorly understood - Characterised by subendothelial and subepithelial deposits - Associated with **hepatitis B** and **C**

Answer 141

- Age 75% of people are 8-16 - Infections - CLL - Acquired partial lipodystrophy (ADP): APL is a very rare condition characterised by the loss of fat and is particularly associated with type II MPGN

Answer 142

It starts one of two ways: Way 1: through hypersensitivity reaction to Hep A or Hep B antigens. These complexes get deposited in the glomerulus and activate the classical complement pathway. Way 2: There is inappropriate activation of the alternative pathway due to over activity of C3 convertase which can be caused by a special IgG antibody called **nephritic factor** Either way there are deposits that end up in the subendothelial space which causes inflammation leading to the thickening of the basement membrane and proliferation of the mesangial cells

Answer 143

- It is caused by nephritic factors which stabilise C3 convertase leading to complement deposits in the basement membrane as opposed to the subendothelial space - Leads to inflammation of the basement membrane and low levels of circulating C3. Will show **tram track appearance on light microscopy**

Answer 144

- **Oedema** - **Oliguria** - **Haematuria** - **Hypertension** - **foamy urine** - **Pink urine**

Answer 145

- U&Es - Urine dipstick - - **C3 and C4 levels:** all types of MPGN are associated with C3 hypocomplementaemia - **Type 1 MPGN**: activates classical component pathway → possible C4 **depletion** - **Type 2 MPGN**: normal C4 - C4 levels can be used to distinguish between type 1 and type 2

Answer 146

Renal biopsy - Type 1 subendothelial and mesangial immune deposits resulting in tram-track appearance - Type 2- Intramembranous dense deposits

Answer 147

- **Oral cyclophosphamide**: offered for all patients with presumed idiopathic MPGN accompanied by nephrotic syndrome **and** declining kidney function - **Oral mycophenolate mofetil (MMF) and oral corticosteroids**: consider in addition to oral cyclophosphamide

Answer 148

Increase in the size of the prostate without malignancy. This causes bladder outlet obstruction and lower urinary tract symptoms.

Answer 149

Men from 51-60 there is a prevalence of 50% above 80 prevalence is 80%

Answer 150

- Increasing age - Family history - Ethnicity more common in black people - Diabetes - Obesity due to increasing circulation of oestrogen

Answer 151

- Basal and luminal cells rely on stimulation from androgens for survival. Such as testosterone (produced by testicles) and dihydrotestosterone (produced by prostate). DHT is produced by 5α-reductase which converts testosterone into the more potent dihydrotestosterone. - As age increases levels of testosterone drop but levels of DHT increase as there is an increase in 5a-reductase activity - This will form hyperplastic nodules to form

Answer 152

the median and lateral lobes are usually enlarged. (transitional zone)

Answer 153

- Hyperplastic nodules will form in the inner portions of the gland typically around the urethra - These nodules will compress the urethra making it more difficult to pas urine. This will mean the smooth muscles of the bladder will have to work harder leading to bladder hypertrophy - The stagnation of the urine in the bladder also promotes bacterial growth leading to UTIs

Answer 154

- Digital rectal exam will find smooth, enlarged and non-tender prostate - Lower abdominal tenderness and palpable bladder: Indicates acute urinary retention Perform bladder scan Requires urgent catheterisation

Answer 155

- Digital rectal exam will find smooth, enlarged and non-tender prostate - Lower abdominal tenderness and palpable bladder: Indicates acute urinary retention Perform bladder scan Requires urgent catheterisation

Answer 156

- Voiding: weak stream and incomplete emptying - Storage: urgency and incontinence - Oliguria: if complete obstruction - Lower abdominal pain and inability to urinate Indicates acute urinary retention

Answer 157

- Prostate-specific antigen (PSA): predicts prostate volume, may suggest cancer if significantly raised but BPH can also raise it - International Prostate Symptom Score (I-PSS): a 7-symptom questionnaire with an additional bother score to predict progression and outcome

Answer 158

- α-1 antagonists: Tamsulosin it is considered first-line. It inhibits the action of noradrenaline and relaxes the smooth muscle. Can cause **Postural hypotension, dizziness, dry mouth and depression** - 5-α reductase inhibitors e.g. finasteride. This will work to reduce the prostate size but can take up to 6 months to work. Can cause: **reduced libido, erectile dysfunction, adn gynaecomastia**

Answer 159

Prostate<30g - **Transurethral incision of the prostate (TUIP):** one or two cuts in the small grooves of the bladder neck to open the urinary channel and allow urine to pass through more easily. Prostate 30-80g **Transurethral resection of the prostate (TURP)**: accessing the prostate through the urethra and “shaving” off prostate tissue from inside using diathermy (heat) Prostate >80g **Transurethral electrovaporisation of the prostate (TUVP)**: prostate tissue is removed using a laser **Open prostatectomy** via abdominal or perineal incision

Answer 160

life-threatening triad of fluid overload, dilutional hyponatraemia and neurotoxicity due to systemic absorption of irrigation fluids during TURP procedure

Answer 161

Prostate adenocarcinoma

Answer 162

- Transitional cell carcinoma - Small cell prostate cancer arising form neuroendocrine cells

Answer 163

- Being tall - Obesity and high fat diet - Use of steroids - Cadmium exposure found in cigarettes, batteries and those in welding industry - BRCA1 and BRCA"

Answer 164

- They commonly arise in the **peripheral zone** of the prostate. This is often a result of a mutation in the luminal cells causing an uncontrollably dividing tumour . - Early on the cancer relies heavily on androgens to survive but can find a way later on in disease to divide without it.

Answer 165

-Spreads to the bines of the vertebrae and pelvis resulting in hip and in back pain

Answer 166

- Asymmetrical, hard and nodular prostate with the loss of the median sulcus - Urinary retention

Answer 167

- Frequency - Dribbling - Haematuria or haematospermia - Dysuria - Bone pain (suggests metastatic disease)

Answer 168

**Multiparametric MRI** is first-line for suspected localised cancer. Reported on using Likert score: - **Prostate-specific antigen (PSA)** - Often increased in patients with prostate cancer - Also raised with increasing age and BPH PSA testing is unreliable, with a high rate of false positives (75%) and false negatives (15%).

Answer 169

1- very low suspicion 2- low suspicion 3- Equivocal 4- probable cancer 5- Definite cancer Prostate biopsy offered to those with scores of 3 or greater

Answer 170

Transrectal ultrasound-guided biopsy (TRUS) Transperineal biopsy Prostate biopsy carries a risk of false-negative results if the biopsy misses the cancerous area. Multiple needles are used to take samples from different areas of the prostate. The MRI scan results can guide the biopsy to decide the best target for the needles.

Answer 171

The Gleason grading system is based on the histology from the prostate biopsies. It is specific to prostate cancer and helps to determine what treatment is most appropriate It is made up of two numbers from the two most prevalent areas of the biopsy and they are graded 1-5. 1 Being well differentiated (good) and 5 being poorly differentiated. A Gleason score of: 6 is considered low risk 7 is intermediate risk (3 + 4 is lower risk than 4 + 3) 8 or above is deemed to be high risk

Answer 172

Active surveillance or observation

Answer 173

External beam radiotherapy directed at the prostate Brachytherapy Hormone therapy Surgery

Answer 174

Involves the implanting of radioactive seeds into the the prostate delivering continuous targeted radiotherapy. The radiation can cause inflammation in nearby organs, such as the bladder (cystitis) or rectum (proctitis). Other side effects include erectile dysfunction, incontinence and increased risk of bladder or rectal cancer.

Answer 175

- it aims to reduce the levels of testosterone that can stimulate the tumour to grow Drugs include **androgen-receptor blockers**-bicalutamide **GnRH agonists**- such as goserelin (Zoladex) or leuprorelin (Prostap) **Bilateral orchidectomy**- removal of the testicles

Answer 176

Early-stage disease has a fantastic prognosis, with an overall 5-year survival rate of approximately 100% for localised prostate cancer. Metastatic disease is associated with a 5-year survival rate of approximately 30%.

Answer 177

Germ cell tumours

Answer 178

Non-germ cell (sex-cord stromal) Lymphomas

Answer 179

- Most common malignancy in young males - Testicular cancer is the 18th most common cancer in males in the UK - Often presents between 15 and 35 years old

Answer 180

- Caucasian - Infertility - Cryptorchidism - Intersex - Mumps - In-utero exposure to pesticides

Answer 181

- **Seminoma**:the most common and best prognosis Non-seminoma - **Teratoma:** composed of tissue from different germinal layers e.g. teeth, common in children. Can contain all types of tissues! (most common form of non-seminoma) - **Yolk-sac tumour:** common in children and aggressive. Made from germ cells that differentiate into yolk sac tissue - **Choriocarcinoma:** rare but most aggressive. Made out of germ cells that differentiate into syncytiotrophoblasts and cytotrophoblasts (cells that help form placenta) - **Embryonal carcinoma:** aggressive and metastasises early. Made from germ cells that turn into embryonic pluripotent stem cells

Answer 182

- Painless lump that will be: Arising from the testicle Hard irregular No transillumination with torch

Answer 183

Sometimes there can be a sharp or dull testicular pain that can be present in the abdomen as well - Symptoms related to raised β-hCG - **Hyperthyroidism** occurs as the alpha subunit of β-hCG mimics TSH - **Gynaecomastia** - **Loss of libido** - **Erectile dysfunction** - **Testicle atrophy**

Answer 184

Ultrasound testicular doppler diagnostic in over 90% of cases

Answer 185

Alpha-fetoprotein – may be raised in teratomas (not in pure seminomas) Beta-hCG – may be raised in both teratomas and seminomas (20%) Lactate dehydrogenase (LDH) is a very non-specific tumour marker

Answer 186

- Surgery to remove the affected testicle - Chemotherapy - Radiotherapy - Sperm banking in case of infertility

Answer 187

- Infertility - Hypogonadism (testosterone replacement needed) - Peripheral neuropathy - Hearing loss

Answer 188

- Lymphatics - Lungs - Liver - Brain

Answer 189

Transitional cell carcinoma (urothelial)

Answer 190

- Squamous cell carcinoma - Adenocarcinoma

Answer 191

- Extended dwell times: not emptying bladder for long periods of time - Alanine - rubber, dye and textile industries - Cyclophosphamide: medication used to treat cancers and autoimmune diseases - Smoking - **Aromatic amines** - **Polycyclic aromatic hydrocarbons (e.g. 2-Naphthylamine)** - Painters and hairdressers

Answer 192

Schistosomiasis causes squamous cell carcinoma of the bladder in countries with a high prevalence of the infection for example Egypt

Answer 193

Palpable suprapubic mass Anaemia

Answer 194

- KEY SYMPTOM **‘Painless’ haematuria**: microscopic or macroscopic - **Dysuria** (pain when urinating) can occur - **Frequency** - Constitutional symptoms e.g. **weight loss**

Answer 195

- Over 45 with unexplained haematuria - Over 60 with microscopic haematuria on urine dipstick plus dysuria or raised WCC The NICE guidelines also recommend considering a non-urgent referral in people over 60 with recurrent unexplained UTIs.

Answer 196

- Flexible cystoscopy and biopsy under local anaesthetic to confirm the presence of a tumour

Answer 197

Transurethral resection of bladder tumour (TURBT) may be used for non-muscle-invasive bladder cancer. The involves removing the bladder tumour during a cystoscopy procedure. Intravesical chemotherapy (chemotherapy given into the bladder through a catheter) is often used after a TURBT procedure to reduce the risk of recurrence.

Answer 198

May be used as a form of immunotherapy,. Giving BCG vaccine (TB) into the bladder is thought to stimulate the immune system to attack the tumour

Answer 199

Overall 5-year survival is 55%, but for distant metastatic disease, this drops to 5%.

Answer 200

Renal cell carcinoma (RCC) is an adenocarcinoma most commonly arising from the epithelium of the proximal convoluted tubule. It is also known as hypernephroma or Grawitz tumour

Answer 201

- Linked to mutations on chromosome 3 - VHL gene is most implicated - Von Hippel-Lindau syndrome can give rise to RCC in younger people

Answer 202

- **Classic triad: haematuria, flank pain, abdominal mass** (seen in 10-15% of patients) - **Constitutional symptoms: e.g. weight loss, fatigue, fever of unknown origin**

Answer 203

- Hypertension - Flank mass - Left sided varicocele

Answer 204

- **Abdominal ultrasound**: a sensitive initial modality to help identify benign vs. malignant lesions but CT/MRI is needed if RCC is suspected

Answer 205

- **CT abdomen/pelvis with contrast**: the definitive test for diagnosis, with 90% sensitivity and 100% specificity in identifying malignancy

Answer 206

super dangerous willy problem or something

Answer 207

Sunitinib and pazopanib which are tyrosine kinase inhibitors

Answer 208

Overall 5-year survival is near 70%, whilst early-stage disease has an excellent 5-year survival of >90%. Survival from metastatic disease has almost doubled since the introduction of Sunitinib, with an overall 5-year survival between 30 and 50% in patients with pulmonary metastasis

Answer 209

Wilms’ tumour is a specific type of tumour affecting the kidney in children, typically under the age of 5 years. It is the chief abdominal malignancy in children

Answer 210

Polycystic kidney disease is a genetic condition where the kidneys develop multiple fluid-filled cysts. Kidney function is significantly impaired. There are a number of associated findings outside the kidneys such as **hepatic cysts** and **cerebral aneurysms**.

Answer 211

Autosomal dominant Autosomal recessive

Answer 212

- PKD-1 on **chromosome 16*** which accounts of 85% of cases and is associated with a more severe phenotype - PKD-2 on **chromosome 4**

Answer 213

- Polycystin proteins are not coded for correctly which allow for calcium influx into to cells to inhibit cell proliferation . - Consequently cells proliferate abnormally and start to express proteins that cause water to be transported into the cyst.

Answer 214

- Leads to the enlargement of certain nephrons which starve healthy nephrons of oxygen. - This results in the activation of RAAS which causes fluid retention and hypertension - Over time when enough nephrons are affected it will result in renal failure

Answer 215

- Cerebral aneurysms - Hepatic, splenic, pancreatic, ovarian and prostatic cysts - Cardiac valve disease (mitral regurgitation) - Colonic diverticula - Aortic root dilatation

Answer 216

- Bilateral flank masses - Hypertension

Answer 217

- Abdominal flank or back pain - Haematuria - Dysuria - Renal colic -- Constitutional features of chronic kidney disease fatigue, weakness, reduced energy - Polyuria, polydipsia, nocturia: excess urine due to poor concentrating ability of kidneys (i.e. not responding to anti-diuretic hormone)

Answer 218

- **Ultrasound**: principle investigations, especially in screening - **Renal MRI/CT**: high sensitivity and good for assessing progression (e.g. kidney size). Useful if concern regarding renal cell carcinoma (RCC)

Answer 219

Known family history - **< 30 years**: ≥3 cysts (unilateral or bilateral) - **30-39 years**: ≥3 cysts (unilateral or bilateral) - **40-59 years**: ≥2 cysts in each kidney

Answer 220

- Blood pressure control - Regular follow up - Maintain adequate hydration - Avoid NSAIDs and anticoagulants - Avoid contact sport to prevent cyst rupture

Answer 221

Vasopressin receptor antagonists (Tolvaptan) can slow the development of the cysts

Answer 222

A gram-negative bacteria. It is an intracellular organism, meaning it enters and replicates within cells before rupturing the cell and spreading to others. Chlamydia is the most common sexually transmitted infection in the UK and a significant cause of infertility.

Answer 223

Aims to screen every sexually active person under 25 years of age for chlamydia annually or when they change their sexual partner

Answer 224

Abnormal vaginal discharge Pelvic pain Abnormal vaginal bleeding (intermenstrual or postcoital) Painful sex (dyspareunia) Painful urination (dysuria)

Answer 225

Urethral discharge or discomfort Painful urination (dysuria) Epididymo-orchitis Reactive arthritis

Answer 226

100mg of **doxycycline** twice a day for 7 days

Answer 227

Chlamydial Conjunctivitis

Answer 228

A gram-negative diplococcus bacteria. It infects mucous membranes with a columnar epithelium, such as the endocervix in women, urethra, rectum, conjunctiva and pharynx. It spreads via contact with mucous secretions from infected areas.

Answer 229

Odourless purulent discharge, possibly green or yellow Dysuria Pelvic Testicular swelling and pain

Answer 230

90% of men and 50% of women are symptomatic.

Answer 231

A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known

Answer 232

Caused by bacteria called **Treponema pallidum**. This bacteria is a spirochete, a type of spiral-shaped bacteria. The bacteria gets in through skin or mucous membranes, replicates and then disseminates throughout the body. It is mainly a sexually transmitted infection.

Answer 233

Primary syphilis involves a painless ulcer called a chancre at the original site of infection (usually on the genitals). Secondary syphilis involves systemic symptoms, particularly of the skin and mucous membranes. These symptoms can resolve after 3 – 12 weeks and the patient can enter the latent stage. Latent syphilis occurs after the secondary stage of syphilis, where symptoms disappear and the patient becomes asymptomatic despite still being infected. Tertiary syphilis can occur many years after the initial infection and affect many organs of the body, particularly with the development of gammas and cardiovascular and neurological complications. Neurosyphilis occurs if the infection involves the central nervous system, presenting with neurological symptom

Answer 234

Primary syphilis can present with: A painless genital ulcer (chancre). This tends to resolve over 3 – 8 weeks. Local lymphadenopathy Secondary syphilis typically starts after the chancre has healed, with symptoms of: Maculopapular rash Condylomata lata (grey wart-like lesions around the genitals and anus) Low-grade fever Lymphadenopathy Alopecia (localised hair loss) Oral lesions

Answer 235

Headache Altered behaviour Dementia Tabes dorsalis (demyelination affecting the spinal cord posterior columns) Ocular syphilis (affecting the eyes) Paralysis Sensory impairment

Answer 236

A single deep intramuscular dose of benzathine benzylpenicillin (penicillin)

Answer 237

Dilated testicular veins within the pampiniform plexus. Around 90% of them occur on the left side

Answer 238

- Occurs most commonly in adolescent boys may affects up to 15% - Seen in around 40% of men with infertility

Answer 239

- They form when there is increased pressure in the testicular veins that drain the pampiniform plexus. - This may be caused by incompetent valves leading to venous reflux. The majority occur on the left side as the testicular vein drains into the renal vein at a shard angle first before IVC.

Answer 240

They can be a sign of renal cancer. The majority occur on the left side so if there is a tumour compressing venous return this could be a cause

Answer 241

- Palpable veins - Scrotum hanging lower

Answer 242

- Painless swelling - Some patients experience **dragging sensation**

Answer 243

- **Testicular examination:** demonstrates dilated veins (bag of worms) - Examination is conducted both standing and lying. - The size of each testicle should be evaluated. - **Doppler USS** may be used in cases of diagnostic uncertainty and to confirm diagnosis. - **Fertility assessments** may be completed. Semen analysis can be sent alongside FSH and testosterone levels.

Answer 244

- Does not drain when lying down - It appears suddenly and is painful - Solitary ride-sided

Answer 245

- **Sub-clinical:** No clinical abnormality, only detected by Doppler ultrasound. - **Grade I (small):** Only clinically palpable with Valsalva manoeuvre. - **Grade II (moderate):** Palpable without Valsalva manoeuvre. - **Grade III (large):** Varicocele is visible through the scrotal skin, easily palpable.

Answer 246

It is the twisting of the spermatic cord with rotation of the tentacle (was autocorrect but thought it's funny, I'm getting really bored)

Answer 247

- Young age - Bell clapper deformity (what a great name this is for a deformity of the testicle). It's when the testicle is high riding and it's horizontal - Cryptorchidism - Trauma

Answer 248

- Abnormal lie - Prehn's negative pain is not relieved on lifting the ipsilateral testicle - Absent cremasteric reflex

Answer 249

- Awful debilitating pain imagine what it would feel like for your testicle to be twisted round and round like a big knot. - Pain can be intermittent and be brought on by exercise - Nausea and vomiting

Answer 250

- Imaging should not be considered if testicular torsion is suspected as it will delay surgery! Think of how much pain the poor man must be in don't wait give him blood back to his testicle - Surgical exploration: should be performed immediately if there is high clinical suspicion as it allows definitive diagnosis and management. Should be performed within 6 hours to prevent irreversible damage (90% salvageable at 6 hours and 10% salvageable at ≥24 hours)

Answer 251

- Bilateral orchiopexy if the testicle is viable. This involves untwisting the testicle and fixing it to scrotal sac. Contralateral one should be fixed as well - Ipsilateral orchiectomy and contralateral orchiopexy if the testicle is not viable : removal of the affected testis and fixation of the contralateral testis to the scrotal sac to prevent contralateral torsion

Answer 252

- **Infertility/ subfertility**: torsion for 10-12 hours results in ischaemia and irreversible damage. Orchiectomy results in decreased spermatogenesis - **Pubertal delay:** may occur, particularly if bilateral orchiectomy is performed; hormone replacement may be required

Answer 253

- Within **4-6 hours** of symptoms, the testis can be saved in the majority of cases - A delay of **10-12 hours** or more results in irreversible ischaemia and necrosis - The testis is salvageable **<10% of** cases at **≥24 hours**

Answer 254

Hydrocele refers to a collection of serous fluid between the parietal and visceral layers of the tunica vaginalis (membrane covering the testes).

Answer 255

Torsion of the appendix testis is a **twisting of a vestigial appendage that is located along the testicle.** This appendage has no function, yet more than half of all boys are born with one. It is also known as **Hydatid of Morgagni (embryonic remnant of the Mullerian duct)** Although this condition poses no threat to health, it can be painful. Usually no treatment other than to manage pain is needed.

Answer 256

Hydrocele refers to a collection of serous fluid between the parietal and visceral layers of the tunica vaginalis (membrane covering the testes).

Answer 257

Simple - overproduction of fluid in the tunica vaginalis Communicating - processus vaginalis fails to close, allowing peritoneal fluid to communicate freely with the scrotal portion

Answer 258

Investigations Scrotal ultrasound Serum AFP and HCG to help exclude malignant teratomas or other germ cell tumours

Answer 259

Management Resolve spontaneously Many of infancy resolve by 2 years **Therapeutic aspiration** or surgical removal

Answer 260

Smooth, extra-testicular, spherical sac of fluid in the head of the epididymis (top of testicle). - also known as a *spermatocele*

Answer 261

- Signs - **Palpable lump** (often multiple and bilateral) - **Well defined** and will **transluminate** since fluid-filled - Symptoms - Can cause **dragging and soreness** - May be **pain** if cysts are large

Answer 262

- Investigations - **Scrotal ultrasound** - Differential diagnosis - **Hydrocele** - **Varicocele** - Management - **Usually not necessary** - **Removed, if symptomatic**

Answer 263

When stretch receptors in the bladder wall sense that the bladder is roughly half full, they send impulses to the sacral spinal cord at levels **S2 and S3 - Pelvis Splanchnic nerves** , known as the micturition center, and the brain, specifically two locations in the pons.

Answer 264

**Micturition reflex** Activation of pelvic splanchnic nerve S2-S4 cause the detrusor muscles to CONTRACT - When the detrusor muscle contract, the change in bladder shape pulls open the internal urethral sphincter - is **made of smooth muscle** **Micturition reflex** also decreases motor nerve stimulation to the external sphincter allowing it to relax as well. At this point, urination should occur, but why don't just wet ourselves every time the bladder is half full?

Answer 265

urination would occur if not for the pons. The pons is the region of the brain that we train to voluntarily control urination. If we want to delay urination, the pontine storage centre overrides the micturition reflex, it overrides it by activating ***SYMPATHETIC, HYPOGASTIRC NERVES T10 - L2*** , leading to DETROUSER RELAXATION, BLADDER NECK CONTRACTION

Answer 266

urination would occur if not for the pons. The pons is the region of the brain that we train to voluntarily control urination. If we want to delay urination, the pontine storage centre overrides the micturition reflex, it overrides it by activating ***SYMPATHETIC, HYPOGASTIRC NERVES T10 - L2*** , leading to DETROUSER RELAXATION, BLADDER NECK CONTRACTION

Answer 267

- Urge incontinence: - Stress incontinence - Mixed incontinence: Overflow incontinence (neurogenic bladder):

Answer 268

- **Diabetes** - **Bladder cancer** - **Parkinson's** - **Multiple sclerosis** - **Prostatectomy** - **Hysterectomy**

Answer 269

Sudden urge to urinate because of an "overactive bladder", followed immediately by involuntary urination typically due to an uninhibited detrusor muscle that contracts randomly. Usually associated with urinary tract infections. Inflammation may trigger the detrusor muscle.

Answer 270

Increased abdominal pressure overwhelms the sphincter muscles and allows urine to leak out. Causes include pregnancy and exertion, like sneezing, coughing, laughing.

Answer 271

Caused by an issue with emptying the bladder. This could be due to a **blockage in urine flow**, e.g. hypertrophic prostate in men which presses on the urethra, or an **ineffective detrusor muscle**. ==> Detrusor cant contract properly so the bladder doesn’t empty properly, and as a result the **bladder fills up and overflows with urine** which leaks through the sphincters. (e.g. in diabetes, neurogenic bladder associated with multiple sclerosis, spinal cord injury)

Answer 272

- Urge incontinence: **frequent urination, especially at night** - Stress incontinence: **urinary leakage with pressure applied to the abdomen** - Overflow incontinence: **weak or intermittent stream or hesitancy**