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extra 4 (m) > GU Problems > Flashcards

GU Problems Flashcards

1
Q

Define AKI

A

A syndrome of decreased renal function, measured by serum creatinine or urine output, occurring over hours to days

  • Rise in creatinine >26 within 48h
  • Rise of creatinine >1.5x baseline within 7 days
  • Urine output <0.5ml/kg/h for >6 consecutive hours
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2
Q

What are the limitations of serum creatinine? But why is serum creatinine superior to urea?

A

Limitations:

  • Muscle mass - lower in elderly, females, amputees; higher in body builders
  • Dilution
  • eGFR can fall to half before creatinine rises past upper limit

Superior:
- Urea is easily influenced by protein turnover (diet, etc) and hydration status

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3
Q

Name the 7 commonest causes of AKI

A
  1. Sepsis
  2. Major surgery
  3. Cardiogenic shock
  4. Other hypovolaemia
  5. Drugs
  6. Hepatorenal syndrome (renal deterioration secondary to cirrhosis)
  7. Obstruction
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4
Q

How can the aetiology of AKI be divided up?

A 
Pre-renal = decreased perfusion to kidneys
Renal = intrinsic renal disease
Post-renal = obstruction to urine
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5
Q

What are some pre-renal causes of AKI?

A

Hypovolaemia

  • Haemorrhage
  • Severe D&V
  • Burns
  • Pancreatitis

Decreased cardiac output

  • Cardiogenic shock
  • MI

Systemic vasodilation

  • Sepsis
  • Drugs
  • Anaphylaxis

Renal vasoconstriction -> hypoperfusion

  • NSAIDs
  • ACEi
  • Hepatorenal syndrome
  • Renal artery stenosis
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6
Q

What are some renal causes of AKI?

A

Glomerular

  • Glomerulonephritis
  • Acute tubular necrosis

Interstitial

  • Drugs
  • Sarcoidosis
  • Infection

Vessels

  • Vasculitis
  • HUS
  • Thrombosis
  • DIC
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7
Q

What are some post-renal causes of AKI?

A

Within renal tract

  • Stone
  • Malignancy
  • Stricture
  • Clot

Extrinsic compression

  • Pelvic malignancy
  • BPH
  • Retroperitoneal fibrosis
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8
Q

Which medications are nephrotoxic?

A

DIAMOND + Li

Diuretics (especially potassium sparing)
Iodine contrasts/immunosuppressants
Antibiotics e.g. aminoglycosides
Metformin
Opioids
NSAIDs
Digoxin
Lithium
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9
Q

What investigations should be done in AKI?

A

Urgent VBG to check K+

Bloods

  • U&Es - serum creatinine, derange electrolytes
  • LFTs - hepatorenal syndrome
  • FBC - platelets (if low do blood film), signs of infection, anaemia in HUS
  • Blood film - HUS

Urinalysis - protein, haematuria, signs of infection

Ultrasound scan within 24 hours unless cause obvious

Monitor urine output

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10
Q

How do you treat AKI?

A

STOP AKI

  1. Sepsis - BUFALO
  2. Toxins - stop nephrotoxins
  3. Optimise blood pressure - 500ml 0.9% sodium chloride given over 15 min (if hypovolaemic)
  4. Prevent harm
    - Treat complications e.g. hyperkalaemia, pulmonary oedema, pericarditis, acidosis
    - Identify cause
    - Review drug chart
    - Renal replacement therapy?
    - Monitor fluids and U&Es
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11
Q

What ECG changes would you see in hyperkalaemia?

A

Tall tented T waves
Increased PR interval
Small/absent P wave
Widened QRS complex

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12
Q

How do you treat hyperkalaemia?

A
  1. Calcium chloride 10ml of 10% OR Calcium gluconate 30ml of 10% - stabilises myocardium but doesn’t reduce K+
  2. Insulin (10 units actrapid) in 50ml 50% dextrose IV over 20 minutes – lowers K+ by driving it into cells
  3. Salbutamol 10-20mg NEB – drives potassium into cells
  4. If they don’t respond to above start haemofiltration/dialysis
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13
Q

What is a complication of uraemia?

A

Pericarditis

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14
Q

What is renal colic?

A

Type of pain that occurs when urinary stones block part of the urinary tract

The pain is produced by ureteric obstruction, increased intraluminal pressure and muscle spasm

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15
Q

Describe the pain caused by a stone in the renal pelvis

A

Dull ache in the loin

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16
Q

What are the different types of calculi in order of how common they are?

A
  1. Calcium oxalate (75%)
  2. Struvite - magnesium ammonium phosphate (15%)
  3. Urate
  4. Hydroxyapatite (usually do to UTI)
  5. Cysteine (usually due to renal tubular defect)
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17
Q

What metabolic disorders predispose you to urinary tract calculi?

A

Hypercalcaemia (hyperthyroidism, hyperparathyroidism, malignancy, sarcoidosis, lithium)
Renal tubular acidosis
Gout
Cysteinuria

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18
Q

What signs might you find on examination of renal stones?

A

Renal angle tenderness - especially on percussion if there is retroperitoneal inflammation
Reduced bowel sounds (as in any severe pain)
Severe pain in testis/tip of penis/labia but not tender on palpation

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19
Q

What is the investigation choice for imaging stones?

A

Non-contrast CT (99% visible, whilst excluding other causes of acute abdomen)

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20
Q

What investigation for renal stones can be done in pregnant patients?

A

USS with doppler

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21
Q

Which stones are radio-opaque and would be seen on KUBXR?

A

Calcium oxalate stones
Struvite stones
Hydroxyapatite stones

22
Q

How do you treat stones <5mm?

A

Increase fluid intake - 90% pass spontaneously
Analgesia - diclofenac IV/PR
Antibiotics - penicillin/gentamicin if infection

23
Q

How do you treat stones >5mm?

A

Medical expulsive therapy

  • Nifedipine (calcium-channel blocker) or tamsulosin (alpha blocker)
  • Extracorporeal shockwave lithotripsy (ultrasound waves shatter the stone)
  • Uteroscopy

Percutaneous nephrolithotomy = keyhole surgery to remove stones if complex

24
Q

What is a risk factor for testicular torsion?

A

Undescended testis

Bell Clapper deformity = abnormally mobile mesentery of testis within tunica vaginalis - bilateral

25
Q

What becomes twisted in testicular torsion?

A

The spermatic cord which brings blood to the scrotum

26
Q

How does testicular torsion classically present?

A

Sudden onset severe scrotal pain that may radiate to the groin or lower abdomen
Nausea & vomiting

27
Q

How can you differentiate testicular torsion from hydrocele?

A

Trans-illumination

28
Q

What signs may be found on examination of testicular torsion?

A

Red, tender, swollen testis

Deming’s sign = affected testicle lies high up

Angell’s sign = opposite testicle lies horizontally

Absent cremaster reflex

29
Q

How do you treat testicular torsion?

A

Emergency surgery within 6-12h to preserve testicle
Orchidopexy = fixation of the testis
Orchidectomy if the testis is non-viable

30
Q

What is the difference between complicated/uncomplicated UTIs?

A

Uncomplicated = normal renal tract structure + function

Complicated = structural/functional abnormality of genitourinary tract e.g. obstruction, catheter, stones, renal transplant, neurogenic bladder

31
Q

What are the most common organisms to cause a UTI?

A

E. Coli = most common (75-95% in community)

  • Staphyloccous saprophyticus (skin commensal)
  • Proteus mirabilis
  • Klebsiella pneumonia
32
Q

What are the symptoms of cystitis?

A
  • Frequency
  • Dysuria
  • Urgency
  • Suprapubic pain
  • Haematuria
33
Q

What are the symptoms of pyelonephritis?

A
  • Fevers and rigors
  • Nausea and vomiting
  • Loin tenderness
  • Septic shock
  • Associated cystitis symptoms
34
Q

What indicates a UTI on urinalysis?

A

Leucocytes

Nitrites

35
Q

What investigation should be done for UTIs in catheterised patients?

A

MSU cultures

Dipstick would almost always be positive so is not useful

36
Q

In which patients should urine cultures be done?

A 
Immunosuppressed
Pregnant women
Renal tract anomaly
Failed to respond to empirical treatment 
Men with history suggestive of UTI
37
Q

Which organism causes hospital/catheter acquired UTI?

A

Pseudomonas

38
Q

What is the treatment for non-pregnant women with a lower UTI?

A

3-6 day course of trimethoprim/ nitrofurantoin

Can only give nitrofurantoin if eGFR > 30

39
Q

What is the treatment for pregnant women with a UTI? Which antibiotics must be avoided?

A

Penicillins (e.g. amoxicillin)/cephalosporins

Avoid:

  • Trimethoprim (1st trimester)
  • Nitrofurantoin (term)
  • Quinolones e.g. ciprofloxacin (all pregnancy)
  • Sulphonamides (all pregnancy)
40
Q

How do you treat men with lower UTI?

A

1-2 week course of trimethoprim/nitrofurantoin

41
Q

How do you treat men with prostatitis?

A

4 week course of ciprofloxacin because it penetrates prostatic fluid

42
Q

What is the treatment for upper UTI?

A
  • 7-10 day course of ciprofloxacin/gentamicin

- Co-amoxiclav and cefalexin can be used

43
Q

Which antibiotics should be avoided in renal impairment?

A
  • Nitrofurantoin
  • Tetracyclines
  • Gentamicin
44
Q

Which antibiotics are best for long-term treatment or prophylaxis of UTIs?

A

Trimethoprim 100mg

Nitrofurantoin 50-100mg

45
Q

What can cause urinary retention in men/women?

A

Both

  • Bladder calculi
  • Bladder cancer
  • Faecal impaction
  • Urethral strictures

Women

  • Prolapse
  • Pelvic mass e.g. malignancy, cyst, fibroid
  • Retroverted gravid uterus

Men

  • BPH
  • Prostate cancer
  • Phimosis
46
Q

What drugs increase the risk of acute urinary retention?

A 
Anticholingergics
Opioids
Benzodiazepines
NSAIDs
Calcium-channel blockers
Antihistamines
Alcohol
47
Q

What is by far the most common cause of urinary retention?

A

BPH

48
Q

What is important to screen for in a patient presenting with urinary retention?

A

Cauda equina syndrome

  • Check lower limb peripheral nervous system
  • DRE for anal tone and prostate
49
Q

How does acute urinary retention present?

A

Painful, distended bladder
Anuria
Possible associated delirium

50
Q

How do you manage acute urinary retention?

A

Immediate and complete bladder compression with catheter

extra 4 (m) (14 decks)

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