GU Flashcards
(292 cards)
1
Q
What is the function of calcitriol?
A
- Increased calcium and phosphate absorption from the gut
2. Suppression of PTH
2
Q
What do people with CKD commonly present with?
A
hyperparathyroidism
3
Q
How does CKD cause hyperparathyroidism?
A
Calcitriol deficiency, calcitriol supresses PTH therefore deficiency –> hyperparathyroidism
4
Q
What is PTH secretion triggered by?
A
Low serum Ca
5
Q
What are 3 ways that PTH increases serum calcium?
A
- Increased bone resorption
- Increased reabsorption of calcium at the kidneys
- Stimulates 1-hydroxylase –> 1,25 dihydroxyvitD –> increased calcium absorption from the intestine
6
Q
What hormones are secreted from the posterior pit gland?
A
- ADH
2. Oxytocin
7
Q
What is the function of ADH?
A
Acts on the CD, increases the insertion of aquaporin 2 channels –> H2O retention
8
Q
What factors stimulate the release of renin?
A
- Sympathetic stimulation
- Decreased BP
- Decreased Na detected by the macula densa
9
Q
What are the functions of ANP?
A
- Renal vasodilator
- Inhibits aldosterone
- Closes ENaC –> decreased Na reabsorption
10
Q
Where does aldosterone act on?
A
CD
11
Q
What is the action of aldosterone?
A
- Increases ENaC and H+/K+ pumps –> increased Na+ absorption and K+ secretion
- This causes H2O retention and increased BP
12
Q
What anatomical structures make up the lower UT?
A
Bladder –> bladder neck, prostate gland –> urethra –> urethra and urethral sphincter
13
Q
What are the functions of the bladder?
A
- Storage of urine
- Converts continuous process of excretion to an intermittent, controlled volitional processes
- Prevents leakage of stored urine
- Allows rapid, low pressure voiding
14
Q
Describe the action of the detrusor muscle.
A
Storage - relaxes
Voiding - contracts
15
Q
Describe the action of the urethral sphincter
A
Contracts during storage and relaxes during voiding.
16
Q
What lines the bladder?
A
Pseudo stratified urothelium lines the bladder
17
Q
Explain the physiology of micturition
A
- Bladder fills and stretch receptors are stimulated
- Afferent impulses stimulate Parasympathetic action of detrusor muscle –> contracts
- Urethral sphincters relax, mediated by the inhibiton of neurones
- PAG is stimulated.
18
Q
Describe the fluid constituent in the body.
A
ICF – 28l
ECF – 14l
19
Q
What is the ECF broken into?
A
Interstital –> 11l
Plasma –> 3l
20
Q
What is the total body fluid?
A
42L
21
Q
How much fluid is
Intravascular?
Extravascular?
A
Intravascular –> 3L
Extravascular –> 39l (ICF+interstitial)
22
Q
What is the function of the prostate?
A
Secretes proteolytic enzymes into the semen which break down clotting factors in the ejaculate
23
Q
What zone does prostate cancer usually affect?
A
peripheral zone.
24
Q
What is a major worry for prostate cancer?
A
METASTASIS
To bone and lymph nodes.
25
What investigations would you do in suspected prostate cancer?
1. Serum --> PSA
2. Urine --> PCA3 and gene fusion products
3. History of LUTS
4. Trans-rectal LUTS
5. Prostate biopsy
6. DRE – Hard, irregular and craggy
26
What are some other causes of raised PSA?
1. Benign prostate enlargement
2. UTI
3. Prostatitis
27
What is the gleason score?
A score in prostate cancer, the higher the score the more aggressive it is.
28
What is the treatment for localised prostate cancer?
1. Observation
2. Radical prostatectomy
3. Radiotherapy
4. Adjuvant hormones
29
What is the treatment for metastatic prostate cancer?
Palliative treatment e.g. hormone therapy – androgen deprivation
30
What is an advantage for prostate cancer screening?
screening can lead to early diagnosis/early treatment and so cure or effective palliation
31
What are the disadvantages of prostate cancer screening?
Uncertain natural history, screening leads to overdiagnosis and over treatment
32
What is acute kidney injury?
Causes raised creatinine and reduced urine output
33
What are the risk factor of AKI?
1. Increasing age
2. CKD
3. HF
4. Diabetes mellitus
5. Nephrotoxic drugs e.g. NSAIDs and ACEi
34
What are the prerenal causes of AKI?
1. Hypertension
2. Heart failure
3. Nephrotoxic drugs
35
What are the renal causes of AKI?
1. Nephrotoxic drugs
2. Vasculitis
3. AI
4. Acute tubular necrosis
5. Glomerulonephritis
36
What is a major complication of AKI?
Hyperkalemia which can lead to arrhythmias
37
How would you prevent Hyperkalemia in AKI?
1. Give calcium gluconate to protect the myocardium
| 2. Give insulin and dextrose
38
How does insulin prevent kyperkalemia in AKI?
Drives K into cells and dextrose is given to rebalance the sugar.
39
What investigations should you perform in a patient with suspected AKI?
1. Check K
2. Bloods, creatinine, U +E
3. Urine output
4. Auto-antibodies
40
What is CKD?
A long term condition where the kidneys function is compromised and may get progressively worse.
41
What are the signs of CKD?
1. Proteinuria
2. Haematuria
3. Impaired eGFR <60ml/min
4. Rise in serum Urea/creatinine
5. Anaemia --> reduced EPO
6. Bone disease
7. Polyneuropathy
8. CV disease
9. Erectile dysfunction
10. Raised PTH
42
What are the causes of CKD?
1. Diabetes mellitus
2. Hypertension
3. Atherosclerotic renal vascular disease
4. Congenital e.g. PKD
5. UT obstruction
43
What is the appropriate management of CKD?
1. Treat underlying cause
2. Slow deteroriation of kidney function e.g. maintain Bp
3. Reduce CV risk e.g. statins, smoking cessation
4. Treat complications e.g. anaemia
5. ESRF --> dialysis or transplant
44
What are the causes of raised UT pressure?
1. Stone in lumen of UUT
2. Tumour in the wall
3. LUT outflow obstruction; BPH, Tumour and stone
4. Bladder obstruction
45
What are the 4 causes of urinary tract colonisation?
1. Diseases that require chemo or steroids e.g. diabetes and immunodeficiency
2. Stones or tumour in the lumen of the UT
3. Poor bladder emptying
4. Catheterisation
46
What would be seen in electron microcsopy in a patient with minimal change disease?
Fused podocytes
47
What is the treatment for minimal change disease?
Steroids
48
What is an example of a loop diuretic and how does it work?
Furosemide --> acts on Na+/k2+/2Cl- transporter (NKCC2)
49
What are 3 potential side effects of Furosemide?
Hypokalemia, hypotension and dehydration
50
What is a potassium sparing diuretic and what does it act on?
Spironolactone --> works on RAAS rather than ion channels.
51
When would spironolactone be given?
In someone with poor K control.
52
What is incontinence?
Lack of voluntary control over urination or defecation.
53
What is the trend in incontinence?
More common in men as men have a bladder neck and a stronger urethral sphincter then women.
54
What information can you get from a bladder diary?
1. Frequency
2. Volume
3. Functional capacity
4. Incontinence
55
What are the 3 types of incontinence?
1. Stress – associated with coughing and sneezing
2. Urgency
3. Mixed – stress + urgency
4. Continuous – due to fistula
56
What is the cause of Stress incontinence in men and women?
In men - neurogenic or iatrogenic (prostatectomy)
| In women - secondary to birth trauma
57
What is the treatment for female stress incontinence?
1. Pelvic floor physio
2. Duloxetine (concerns over SE’s)
3. Surgery
58
What is the treatment for male stress incontinence?
1. Artificial sphincter
| 2. Sling
59
What is an overactive bladder?
Urgency and frequency in the presence of local pathology that would account for these symptoms.
60
What is the treatment of an overactive bladder?
- Behavioural E.g. limit caffeine
- Pelvic floor physio
- Muscarinic antagonists
- Beta 3 agonists
- Botox
- Cystoplasty
61
What is the role of PMC/PAG in micturition
Coordination and completion of voiding.
62
Which group's are at risk of hypervolemia?
1. AKI patients
2. CKD patients
3. Heart failure patients
4. Liver failure patients
63
Describe the presentation of Hypervolemia?
- HR is normal, BP normal or high
- JVP is high
- Tissue turgor is normal
- Urine output is normal
- Weight is increased
64
What are the symptoms of hypervolemia?
shortness of breath and peripheral oedema
65
What is the effect on
creatine
Hb
haematocrit
in hypervolemia?
All reduced
66
How do you manage hypervolemia?
1. Diuretics e.g. furosemide
2. Fluid restriction
3. Treat reversible causes
67
What are the reasons for a rising creatinine?
1. Aggressive diuretics
2. Extravascular hypervolemia but intravascular hypovolemia
3. Progression of CKD
68
What are the signs of hypovolemia?
- Tachycardia and Hypotension
- Urine output reduced
- Tissue turgor is reduced
- Jugular venous pressure is low
- Weight is also reduced
69
What are the symptoms of hypovolemia?
Thirst and dizziness
70
What is the effect on
Creatinine
Haematocrit
Hb
in hypovolemia?
All raised
71
Which groups are at risk of hypovolemia?
1. Elderly
2. Ileostomy patients
3. Short bowel syndrome
4. Bowel obstructions
5. Those taking diuretics
72
Where may fluid accumulate in hypovolemia?
- Pulmonary oedema
- Pleural effusion
- Ascites
- Bowel obstruction
- Intra-abdo collection
73
What is the management of hypovolemia?
1. Oral fluid
2. IV fluid if very ill
3. Treat reversible causes
74
What are 3 examples of isotonic solutions?
1. 5% Dextrose
2. 0.9 NaCl
3. Hartmann’s solution
75
Describe the movement of Crystalloid fluid
Intravascular to extravascular e.g. Gelofusine
Small molecules can pass through the CM.
76
What is haematuria?
Blood in urine
77
What are the causes of haematuria?
1. Kidney tumour, trauma, stones and cysts
2. Ureteric stones or tumours
3. Bladder infection, stones or tumours
4. BPH or prostate cancer
78
A patient presents with haematuria, what tests should you order?
1. Urinalysis
2. Urine cytology
3. Abdo US and Abdo CT
4. Cystoscopy
79
What is renal colic?
A pain you get when urinary stones block part of your urinary tract (Kidneys, ureter, bladder and urethra)
80
What are the symptoms associated with renal colic?
- Colicy pain
- Nausea and vomiting
- Pain during urination
- Severe low abdo or groin pain
- Urinating less frequently
81
What are the causes of renal colic?
1. UT stones
2. UTI
3. Pyelonephritis
82
What investigations would you do for renal colic?
- Bloods inc, calcium, phosphate, urate
- Urinalysis
- MCS MSU
- NCCT-KUB – gold standard
83
What is the treatment for Renal colic?
- Analgesia e.g. NSAIDs – diclofenac
- Anti-emetics
- Check for sepsis
- Treat underlying cause.
84
What are the functions of the kidney?
1. Filters and exretes waste products from the blood
2. Regulates BP
3. Retains albumin
4. Reabsorption of Na, Cl, K, glucose, H2O, Amino acids
5. Synthesis EPO
6. Converts 1-hydroxyvitD to 1.25-dihydroxyvitD
85
What is the equation for GFR?
Um x urine flow rate / Pm
- Um = concentration of marker in urine
- Pm = concentration of substance in plasma
86
What is a typical GFR?
120ml/min
87
What is used to estimate GFR?
Creatine
88
What are 3 features of a good marker substance?
1. Not metabolised
2. Freely filtered
3. Not reabsorbed/secreted
89
What is the affect of afferent arteriole vasoconstriction?
Decreased GFR
90
What is the affect of efferent arterial vasoconstriction?
Increased GFR
91
Where does the bulk of reabsorption happen in the kidneys?
PCT
92
What are 7 things absorbed at the PCT?
1. Sodium
2. Chlorine
3. K
4. Glucose
5. Water
6. Amino acids
7. Bicarb
93
What is fanconi syndrome?
failure of the nephron to absorb essential ions. Sugar and AA are therefore present in the urine.
94
What is the signs of fanconi syndrome?
1. Sugar in the urine
2. Acidotic due to bicarb in the urine.
3. Rickets/ osteomalacia
95
What are the causes of fanconi syndrome?
1. Myeloma
| 2. Cystinosis
96
Why do we have a countercurrent multiplier system?
Generates hypertonic medullary interstitium for H2O Reabsorption
Na+ moves out of the ascending limb which increases medullary osmolality --? H2O follows
97
Describe tubuloglomerular feedback
Macula Densa cells of the DCT lie between the AA and EA. They detect NaCl and use this as an indicator of GFR.
98
What happens when the macula densa detect's raised NaCl
AA Constriction
99
What happens when the macula densa detects lowered NaCl
Renin secretion
100
What two cell types exist in the CD?
1. Principal
| 2. Intercalated
101
What does aldosterone do?
Aldosterone regulates sodium reabsorption
102
How can aldosterone cause hypokalemia?
- Aldosterone secretion causes increases sodium reabsorption
- Sodium reabsorption leads to K secretion therefore Hypokalemia
103
How do NSAIDs effect GFR?
NSAIDs inhibit prostaglandins --> so lead to AA vasoconstriction = Reduced GFR.
104
How do ACEi effect GFR?
ACEi cause EA Vasodilation = reduced GFR.
105
What factors govern renal K?
1. Na+
2. Aldosterone
Sodium is responsible for volume control
106
What hormones increase Na reabsorption?
1. Aldosterone
| 2. Angiotensin 2
107
What can decrease Na absorption?
ANP
108
What is the function of EPO?
Stimulates bone marrow to allow for RBC maturation.
109
What is benign prostatic hyperplasia?
Prostate enlargement
110
What is PSA?
a glycoprotein secreted by the prostate into the blood stream
111
What are the symptoms of Benign prostatic hyperplasia?
1. Increased frequency of micturition
2. Nocturia
3. Hesitancy
4. Post-void dribbling
112
What is the treatment of Benign prostatic hyperplasia?
1. Mild symptoms – watchful waiting
2. Alpha 1 antagonists e.g. tamulosin
3. 5-alpha reductase inhibitors
113
How does Tamsulosin work?
By relaxing the smooth muscle in the bladder neck and prostate so increases urinary flow, improving obstructive symptoms.
114
How do 5-alpha reductase inhibitors work?
By blocking the conversion of testosterone to dihydrotestosterone (the androgen responsible for prostatic growth)
115
What investigations should be done in benign prostatic hyperplasia to rule out carcinoma?
1. IPSS prostate score questionnaire
2. DRE
3. PSA to rule out prostate cancer
116
What is the treatment for prostate carcinoma?
- Radial prostatectomy or radiotherapy
| - Remove the androgenic drive e.g. bilateral orchidectomy
117
What are the signs of prostate carcinoma?
1. Increased frequency micturition
2. Nocturia
3. Hesitancy
4. Post-void dribbling
SAME AS BENIGN PROSTATIC HYPERPLASIA.
118
What tests for prostate carcinomas would you perform?
1. Trans-rectal USS of prostate
2. Serum PSA – will be elevated
3. Trans-rectal prostate biopsy
119
What is sepsis?
Potentially life threatening response to an infection.
120
What is the treatment of sepsis?
1. High flow oxygen
2. Take blood cultures
3. IV abx and fluids
4. Check lactate
5. Monitor hourly urine output
Drainage to relieve pressure
121
How would you diagnose urosepsis?
A symptomatic UTI combined with 1> of
- Microbial resistance
- Immunosuppression
- Pressure
122
Which 2 groups would you treat for bacteriuria?
Pregnant ladies and children
123
What is septic shock?
Severe sepsis with persistent hypertension.
124
What are the symptoms of Acute urinary retention?
1. Painful
2. Sudden onset
3. >500ml of urine in bladder
125
What is a rare but serious cause of Urinary retention?
Spinal cord compression
126
What are the causes of urinary retention?
- UT stones
- Tumours
- Benign prostatic hyperplasia
127
What investigations in Acute urinary retentions would you order?
1. Clinical examination – palpable bladder
2. MRI
3. Bloods
4. Neuro tests – pain in back, loss of anal reflex all for spinal cord compression
128
What is the treatment in acute urinary retention?
1. Reassurance
2. Catheterise
3. Pain relief
129
What do the cavernous nerves carry?
- Parasympathetic – S2-S4
| - Sympathetic T11-L2
130
What waste products are removed from the blood in dialysis?
1. Urea
2. Creatine
3. Potassium
4. Phosphate
131
How frequent are
Hospital haemodialysis
Home haemodialysis
Hospital haemodialysis --> 3-5 hours 3 times a week
| Home haemodialysis --> 2-3 hours, 5 times a week
132
Why do patients with home haemodialysis require less dietary restriction?
Due to more frequent haemodialysis.
133
What are the complications of haemodialysis?
1. Hypotension
2. Cramps
3. Nausea
4. Chest pain
5. Fever
6. Blocked or infected dialysis catheter
134
Who would be suitable for haemodialysis?
1. People who live alone/frail/elderly
2. People who fear operating machines
3. People who are unsuitable for PD e.g. previous abdo surgery, abdo hernia
135
How often is CAPD and APD done?
CAPD is done in 30-40 min exchanges, 3-5 times a day.
| APD is done once overnight (8hrs)
136
What is peritoneal dialysis?
- Access point is when a peritoneal is placed into the peritoneal cavity through a SC tunnel
137
What are complications of peritoneal dialysis?
1. Infection e.g. peritonitis/catheter exit site infection
2. Peri-catheter leak
3. Abdo wall herniation
4. Intestinal perforation
138
Who is peritoneal dialysis good for?
1. Young people/those in full time work
2. People who want control/responsibility for their care
3. People with severe HF
139
What is the physiological process of an erection?
1. Parasympathetic stimulation
2. Arteriolar dissection
3. Smooth muscle relaxation
4. Testosterone
140
What is the role of NO in erections?
NO is responsible for the smooth muscle relaxation in an erection
- Causes a fall in cytoplasmic calcium smooth muscle relaxation
141
What are the main causes of erectile dysfunction?
1. Organic e.g. vasculogenic, neurogenic, hormonal and anatomical
2. Psychogenic
142
What are the characteristics of psychogenic erectile dysfunction?
1. Sudden
2. Situational
3. Younger males affected
143
What are 4 risk factors for Erectile dysfunction?
1. Obesity
2. Lack of exercise
3. Smoking
4. Diabetes mellitus
144
What are the non pharmacological management of ED?
1. Lose weight stop smoking
| 2. Education and counselling of patient and partner
145
What is the first line pharmacological treatment of ED?
Phosphodiesterase inhibitors e.g. Viagra, Cialis --> vasodilation so increase arterial blood flow.
146
What is the second line pharmacological treatment of ED?
1. Intracavernous injections
| 2. Vacuum devices
147
What is the third line pharmacological treatment of ED?
1. Penile prosthesis implantation
148
What is priapism?
Erection lasting over 4 hours, permanent ischaemic damage as a consequence.
149
Describe the epidemiology of Kidney stones?
10-15% lifetime risk, Males > females 2:1 ratio, common among 30-50-year olds.
150
What are the potential causes of stones in the UUT?
1. Congenital abnormalities
2. Metastable urine
3. Hypercalcaemia/ high urate/ high oxalate
4. Dehydration
5. Infection
151
What is the pathophysiology of stone formation?
Stones form from crystals in supersaturated urine --> 80% are calcium based e.g. calcium oxalate
152
What are the symptoms of stones?
1. Loin pain groin pain
2. Renal colic – pain caused by a blockage in the urinary tract
3. UTI symptoms e.g. dysuria, urgency and frequency
4. Recurrent UTI’s
5. Haematuria
153
How can you prevent Stones?
1. Staying well hydrated
2. Low salt diet
3. Healthy protein intake
4. Reduced bmi
5. Active lifestyle
6. Deacidification of urine can prevent uric acid stones
154
What is the treatment for stones?
1. Conservative e.g. if stone is <5mm and in a safe location w/ no symptoms
2. Medical e.g. nifedipine (CCB)
3. Lithotripsy – fragment stones which will pass spontaneously
4. Surgical – ureteroscopy – PCNL for larger stag horn ureteric tones
155
Treatment for stag horn ureteric stones
- Analgesia and anti-emetics
- Observe for sepsis
- PCNL
156
Where do UT stones usually form?
CD
157
Where do UT stones usually get stuck?
- Ureteropelvic junction
- Pelvic brim
- Vesoureteric junction
158
Where does a transplanted kidney lie in the recipent?
Illiac fossa
159
What is the selection criteria for a donor for kidney transplant?
1. Blood relative
2. ABO Blood group compatible
3. HLA identical
4. Excellent medical condition and normal renal function
160
What 3 conditions can exclude a live kidney donation
1. Renal parenchymal disease
2. History of stones/frequent UTI/Hypertension/DM
3. Recent malignancy
161
What is the criteria for a cadaver donor?
1. Irreversible brain damage
2. Normal renal function
3. No evidence of pre-existing renal disease or transmissible disease
4. ABO Compatible and best HLA possible
162
What kidney function tests can you perform?
1. Serum creatine
2. Creatinine clearance
3. Urinalysis
4. Urine culture
5. GFR
163
Give 5 contraindications for renal transplant
1. ABO incompatibility
2. Cytotoxic Ab’s against HLA antigens
3. Recent malignancy
4. Active infection
5. AIDs
6. Morbid obesity
7. Age > 70
164
How would you assess recipent and donor in transplants?
1. HLA tissue typing (important to match DR antigens)
2. Lymphocytotoxic cross matching – check there are no performed Ab against HLA antigens
3. ABO blood group compatibility
165
What 4 factors affect the longevity of a renal allograft?
1. Age
2. HLA matching
3. Ischaemia time
4. Number of acute rejection episodes
5. Ethnicity
166
What are the 2 major causes of Renal allograft failure?
chronic rejection and death with functioning graft
167
What are 2 causes of death post kidney transplant
CV disease and infection
168
What are 3 types of renal allograft rejection?
1. Hyper-acute
2. Acute
3. Chronic
169
Describe hyper-acute allograft rejection
preformed antibodies against HLA antigens of donor organs
Can be from blood transfusion, pregnancy, prior transplant and AI disease
170
What would cause immediate graft loss?
Fibrinoid necrosis
171
What is acute allograft rejection?
Activated T lymphocytes, occur within first 6 months --> often reversible w/ steroids
172
What is chronic allograft rejection?
Slow and gradual decline in renal function, accompanied by proteinuria
173
What is the Banff criteria?
diagnose allograft rejection
174
What are the consequences of chronic immunosuppression?
1. Malignancy
2. Infection
3. SE’s of other drugs
175
What is transitional cell carcinoma?
AKA Urothelial carcinoma, effecting the
1. Bladder
2. Ureter
3. Renal pelvis
176
What is the epidemiology of TCC?
75% male and over 40
177
What are the risk factors for TCC?
- Smoking
- Occupational exposure e.g. working in rubber factories
- Increasing age
- Male gender
- Family history
178
What are the symptoms for TCC?
1. Painless haematuria
2. Frequency
3. Urgency
4. Dysuria
5. UT obstruction
179
What investigations would you order in suspected TCC?
1. Urine dipstick
2. Blood tests
3. Flexible cystoscopy = diagnostic
4. Imaging of the URT
5. TURBT --> trans urethral resection of bladder tumour
180
What are the risks of flexible cytoscopy?
1. UTI
| 2. Problems passing urine
181
Why would you image the full URT in suspected TCC.
You would image the URT with suspected transitional cell carcinoma as you need to confirm there is no other TCC in the UT
- CT, IVU, USS, and Xray
182
What staging does TCC use?
TMN staging
183
Why would you do a trans urethral resection of bladder tumour (TURBT)?
Histological and staining analysis.
184
What is the treatment for non-muscle invasive bladder cancer?
1. TURBT
| 2. Chemotherapy to reduce the risk of recurrence and progression to muscle invasion
185
What is the treatment for muscle invasive bladder cancer?
1. Radical cystectomy = gold standard
2. +/- neo-adjuvant chemo
3. Radical radiotherapy if not fit/unwilling to undergo cystectomy
186
What is the treatment for T4 TCC (invasion beyond the bladder)
1. Palliative chemo/radiotherapy
| 2. Chronic catheterisation for pain
187
What helminth can cause Bladder cell carcinoma?
Schistosomiasis
188
What is the epidemiology of Renal cell carcinoma?
Incidence increases in those above 60 and male.
189
What are the risk factors for renal cell carcinoma?
smoking, obesity and hypertension
190
What disease can cause renal cell carcinoma?
Von Hippel lindau disease can cause renal cell carcinoma
- AD, Loss of tumour suppressor gene VHL.
- Lots of benign cysts grow --> some turn cancerous
191
What are the signs of renal cell carcinoma?
- Haematuria
- Flank mass
- Loin pain
192
Do RCC present early or late?
RCC are rarely presenting with symptoms as they are often found early through incidental imaging
193
What may RCC metastasise too?
lymph nodes
lungs
bones
194
What is a variocele?
An abnormal enlargement of the pampiniform venous plexus in the scrotum
195
Give two causes of varioceles?
- RCC may cause L sided varicocele
| - If the tumour obstructs where the gonadal vein drains into the renal vein.
196
What investigations would you order in suspected RCC?
- Ultrasound
- Bloods FBC + U+E, LFT, Ca profile
- Abdo CT w/ contrast
- Bone scan for boney metastasis
197
What is the treatment for localised RCC?
Surgical partial nephrectomy
198
What is the treatment for metastatic RCC?
Palliatve nephrectomy + radiotherapy
199
What is the bozniak classification?
To help differentiate between benign cystic lesions and cancerous cystic lesions
200
What is pyelonephritis?
Inflammation secondary to infection of the renal parenchyma and soft tissues of the renal pelvis
201
What is the cause of pyelonephritis?
UPEC. Typically, P pili --> infection usually in the bladder.
202
What are the symptoms of pyelonephritis?
1. Loin pain
2. Fever
3. Pyuria
May also have a severe headache and be fluid deplete
203
What investigations would you order in pyelonephritis?
1. Urinalysis
2. MCS MSU
3. Bloods – raised WCC, ESR and CRP
204
What is the treatment for pyelonephritis?
IV fluids and antibiotics e.g. gentamicin/co-amoxiclav
- Drain obstructed kidney
- Catheterise if necessary
- Analgesics
205
What is the likely cause of pyelonephritis in children?
Likely cause of pyelonephritis in children reflux or structural/functional abnormalities.
206
What are LUT symptoms?
Storage problems
1. Straining
2. Hesitancy
3. Incomplete emptying
4. Poor flow
207
A 50yo man presents with LUT symptoms, what is the likely cause?
Benign prostatic hyperplasia.
208
What investigation would you order in a patient with LUT symptoms?
1. Urinary tests e.g. dipstick
2. Urinary flow; maximum flow rate and residual volume are important
3. Symptom assessment; International prostate scoring system
4. Blood tests e.g. PSA, U+E
209
What are the causes of nocturnal polyuria?
1. Habiutal
2. Congestive cardiac failure
3. Sleep apnoea
210
Describe the treatment for mild LUTs
reassurance, watch and wait
211
Describe the treatment for moderate LUTs
Fluid management, avoid caffeine and bladder drill
212
Describe the pharmacological management of LUTs
- Alpha 1-blockers e.g. tamulosin
| - 5 Alpha-reductase inhibitors
213
How do Alpha 1 blockers and 5-alpha reductase inhibitors work in the treatment of LUTs?
Alpha 1-blockers cause vasodilation and so reduced resistance and bladder outflow
5- Alpha reductase inhibitors inhibit conversion of testosterone to dihydrotestosterone so reduce prostate size.
214
What is a side affect of using Alpha 1-blockers in treatment of LUTs?
Tamsulosin
Hypotension + retrograde ejaculation
215
What is the surgical treatment for benign prostate enlargement?
Transurethral resection of the prostate
216
What are the consequences of untreated LUTs?
Consequences of untreated LUTS
1. Bladder calculi (stones)
2. UTI
3. Urinary incontinence
4. Reduced QOL
5. Acute urinary retention
217
What is Cystitis?
Inflammation of the bladder secondary to infection
218
What are the symptoms of cystitis?
1. Dysuria
2. Frequency
3. Urgency
219
What are the risk factors for cystitis?
1. Obstruction
2. Previous damage to the bladder epithelium
3. Bladder stones
4. Poor bladder emptying
220
What is the treatment for cystitis?
- Over the counter painkillers
| - Antibiotics if infection is confirmed
221
What are the consequences of glomerulonephritis?
1. Leaky glomeruli --> haematuria and proteinuria
2. High BP
3. Deteriorating kidney function
222
What is the pathophysiology of glomerulonephritis?
Immunologically mediated – immunoglobulin deposits and inflammatory cells
223
How can glomerulonephritis cause sepsis?
Becuase you lose Ig in the urine.
224
What are the causes of acute nephritic syndrome
1. ANCA
2. Goodpastures
3. SLE
4. Post streptococcal infection – deposits immune complexes in the kidney
5. IgA nephropathy
225
What is the primary cause of acute nephrotic syndrome
Minimal change disease --> mainly in kids
226
What investigations would you do in suspected glomerulonephritis/acute nephrtic syndrome?
1. Renal biopsy
2. Urine dipstick ++++ protein
3. Bloods – low serum albumin
4. Look for AI
227
What are the signs of acute nephrtiic syndrome?
1. Inflammation of glomeruli
2. Haematuria and Proteinuria
3. Hypertension
4. Fluid overload
5. Oliguria
6. Red cell clasts
228
What signs are needed to make a diagnosis of nephrotic syndrome?
1. Hypoalbuminaemia
2. Oedema
3. Heavy proteinuria
4. Hypercholesterolaemia
229
What can nephrotic syndrome be secondary to?
1. Diabetes
2. Amyloid
3. Infection
4. SLE
5. Drugs
230
What are the consequence of nephrotic syndrome?
Sepsis and venous thromboembolism.
231
Treatment for nephrotic syndrome
1. Treat complications e.g. diuretics for oedema, ACEi for proteinuria
2. Treat the underlying cause
3. Statins and anti-coagulation e.g. warfarin
4. In children give steroids as minimal change disease is the most likely cause of disease
232
What is the pathophysiology behind nephritic syndrome?
Immune complex deposition in glomerular capillary -->neutrophil recruitment --> inflammation and damage to the glomerular capillary membrane RBC, WBC, Protein etc leaks into the Bowmans capsule and is excreted in the urine.
Simple --> podocytes or the BM aren’t working properly and so huge amounts of protein leaks into the BC and is excreted in the urine.
233
What is the difference between nephrotic and nephritic disease?
Nephrotic disease - Damage to glomeruli allowing too much protein to pass through the urine. DOESNT INCLUDE BLOOD.
Nephritic disease - Proteinuria and haematuria, glomeruli injury.
234
What is the treatment for renal artery stenosis?
ACE inhibitors e.g. ramipril
235
A patient presents complaining that they are hardly passing any urine and in the small amount of urine they do pass there is blood in it. On further questioning they tell you they have recently finished a course of antibiotics (amoxicillin) for a chest infection they had 2 weeks ago. Their BP is high. What is the likely cause?
Nephrotic syndrome --> THEY PASS BLOOD!
236
Is focal segmental glomerulosclerosis a cause of nephritic or nephrotic syndrome?
Nephrotic syndrome
237
A 50 y/o M presents with haematuria. On examination he has HTN, increased serum Cr and urea, proteinuria and bilateral palpable costo-vertebral angle masses. You take a family history and find out that his dad died of a sub-arachnoid haemorrhage. What is the most likely diagnosis?
- ADPKD.
- Normally people present around 50 y/o.
- Raised creatinine and urea indicate a kidney problem.
- The kidneys can be HUGE in ADPKD hence the palpable masses.
- Intracranial haemorrhages are an extra-renal manifestation of ADPKD.
238
Why might someone with ADPKD have bilateral palpable costovertebral masses?
Cysts increase in size and cause renal enlargement. Often the kidney's can be HUGE!
239
A patient presents with haematuria. A MSU sample is taken and a blood film is done. The RBC's look dysmorphic. Where in the urinary tract is the problem likely to be?
Dysmorphic signify glomerular origin, if RBC look normal its likely a LUT problem.
240
Most common cause of renal cancer in kids
Wilms tumour
241
What is the symptoms of type 1 prostatitis? (Acute bacterial prostatitis)
1. Systemically unwell, fever
2. Rigors
3. Voiding LUTS (straining, hesitancy, incomplete emptying, poor flow)
4. Pelvic pain
242
What are the symptoms of Type 2 prostatitis (chronic bacterial prostatitis)
1. Recurrent UTI’s
2. Pelvic pain
3. Voiding LUTS (straining, hesitancy, incomplete emptying, poor flow)
4. Uropathogens in urine
243
How long should a patient have symptoms of type 2 prostatitis for it to be chronic?
3 months
244
What is the treatment of Type 1 prostatitis (acute bacterial prostatitis)
IV Abx e.g. gentamicin, co-amoxiclav for 2-4 weeks.
245
What is the treatment of Type 2 Prostatitis (chronic bacterial prostatitis)
4-6 weeks quinolone e.g. ciprofloxacin
246
What is the symptoms of Type 3 prostatitis (pelvic pain syndrome)
Pelvic pain.
247
What investigations would you do in prostatitis?
1. Urinalysis and MSU
2. Semen cultures
3. STI screen
4. Bloods including MCS
248
What is the NIDDK-classification for prostatitis?
1. Type 1 – acute bacterial
2. Type 2 – Chronic bacterial
3. Type 3a – inflammatory chronic pelvic pain syndrome
4. Type 3b – Non-inflammatory chronic pelvic pain syndrome
5. Type 4 – asymptomatic inflammatory prostatitis
249
What is the cause of urethritis?
STIs e.g. gonorrhoea and chlamydia
250
What are the symptoms of urethritis?
Urethral pain and dysuria
251
Describe the treatment of urethritis
Treat the underlying infection with Antibiotics + education
252
What is epididymo-orchitis?
Inflammation of the epididymis and testicle
253
What are the symptoms of epipidymo-orchitis?
- Sudden onset tender swelling
- Dysuria
- Sweats/fever
254
What is the aetiology of epipidymo-orchitis?
- If under 35 = ST e.g. chlamydia
| - If over 35 = UTI
255
What investigations would you do in epipidymo-orchitis?
1. Void urine
2. Urethral swab
3. MSU
Rule out testicular torsion
256
What is the treatment for epipidymo-orchitis?
1. If STI aetiology suspected – refer to GUM and maybe give doxycycline
2. If UTI aetiology suspected give quinolone (ciprofloxacin)
257
What are UTIs?
Inflammatory response of the urothelium to bacterial invasion, usually associated with bacteriuria and pyuria.
258
What are 3 causative organisms of UTIs?
1. Uropathogenic strains of e.coli UPEC
2. CNS e.g. s. saprophyticus
3. Proteus mirabilis
4. Enterococci
5. Klebsiella pneumonia
259
What is the epidemiology of UTIs?
more common in women with short urethras and it’s proximity to the anus
260
What is the pathology of UTIs?
Organisms colonise the urethral meatus and ascend via the transurethral route
261
How can bacteria enter the UT?
- Sex
| - Catherization
262
What are 3 bacterial virulence factors that aid their ability to cause UTIs?
1. Fimbriae/pilli that adhere to urothelium
2. Acid polysaccharide coat that resists phagocytosis
3. Toxins
4. Enzyme production e.g. urease
263
Why does the vagina have lots of lactobacilli?
Maintain low pH for defence.
264
What does Type 1 pili bind to and what does it cause?
Uroplakin and LUTI
265
What does Type P Pili bind to and what does it cause?
Binds to gylcoproteins on urothelium to cause UUTI's
266
Why are post menopausal women more likely to get UTIs?
1. pH rises --> increased colonisation by colonic flora
| 2. Reduced mucus secretion
267
What is the host defence mechanisms against UTI's?
1. Antegrade flushing of urine
2. Tamm-horsfall protein
3. GAG layer
4. Low urine pH
5. Commensal flora
6. Urinary IgA
268
What is pyuria?
presence of leukocytes in the urine
269
Give 3 examples of LUTIs
1. Cystitis
2. Prostatitis
3. Epididymitis
4. Urethritis
270
Example of an UUTI
Pyeloneprhitis
271
Investigations for a UTI
1. Take a good history
2. Urinalysis – multistix SG.
3. Microscopy – culture and sensitivity of mid-stream urine.
4. In recurrent/complicated UTI renal imaging is important
272
What is the difference between complicated and uncomplicated UTI's?
- Someone with an abnormal UT
- A man
- A pregnant lady
- Children
- The immunocompromised
- If it is recurrent
273
First line treatment for uncomplicated UTIs
1. Trimethoprim or nitrofurantoin for 3 days.
| 2. Increased fluid intake and regular voiding
274
How does trimethoprim work?
Affects folic acid metabolism
275
First line treatment for complicated UTIs
1. Same for an uncomplicated UTI but MCS MSU is necessary
| 2. Patient would take a longer Abx course tailored to sensitivity
276
What are the causes of recurrent UTIs?
1. Re-infection
2. Bacterial persistence
3. Unresolved infection
277
What is the definition of a recurrent UTI?
2 episodes in 6 months of >3 in 12 months.
278
What is the management of recurrent UTIs?
1. Increased fluid intake
2. Regular voiding
3. Void pre and post intercourse
4. Abx prophylaxis
5. Vaginal oestrogen replacement
279
What is the pathophysiology of congenital polycystic disease.
Genetic mutation --> predisposition to cyst development --> cell proliferation and loss of planar polarity -->fluid secretion and cyst expansion
280
What is the pathophysiology of acquired polycystic disease?
Cysts develop over time --> renal injury/ischaemia causes abnormal cell proliferation
281
What are the 4 congenital causes of renal cysts?
1. ADPKD
2. ARPKD
3. VHL
4. OFD1 (Oral-facial-digital syndrome 1)
282
What is autosomal dominant polycystic kidney disease?
An autosomal dominant condition characterised by progressive cyst development – cysts increase in size --> renal enlargement and loss of function causes kidney failure
283
When does ADPK present?
Around 50 years old as there is more cysts.
284
What is the cause of ADPK?
Mutation in PKD1 (more severe) and PKD2 is associated.
285
What are the signs of ADPK?
1. Hypertension
2. Haematuria
3. Polyuria
4. Abdo/loin pain
5. Palpable bilateral costo-vertebral masses
286
How do you diagnose ADPK?
1. Symptoms
2. Family history
3. High BP
4. Urinalysis
5. USS
287
What is a prognostic marker for ADPKD?
TKV - total kidney volume
288
What does a mutation in HNF1 beta cause?
AD tubulointerstitial kidney disease
289
What is the difference in epidemiology of ARPK and ADPK?
ADPKD presents in middle age whereas ARPKD starts in infancy
290
What are the features of acquired renal cystic kidney disease?
1. No genetic mutation
2. No family history
3. Normal kidney size
4. Risk factor for renal cell carcinoma
291
Where is the access point in haemodialysis?
AV fistula
292
Why might some patients have a PTFE graft instead of an AV fistula?
Pt may have atherosclerotic veins or previous fistulas.
