1
Q
causes of urinary retention
A
- obstruction of the urethra
- nerve problems
- medications
- weakened bladder muscles
2
Q
history of acute urinary retention
A
- gradual worsening voiding symptoms
- UTI symptoms
- clot formation (tumour)
- back pain (cauda equina)
- MS presentation
- gynea symptoms
- new meds
- bowel habit
3
Q
examination for acute urinary retention
A
- uncomfortable, tachycardia, palpable bladder
- neuro: perineal + perianal sensation + anal sphincter tone , lower limb tone, sensation and reflexes
- prostate exam
4
Q
management for acute urinary retention
A
- catherisation + note residual urine volume + dipstick for UTI
- PSA
- ultrasound pelvis for masses (women)
5
Q
common causes of haematuria
A
- malignancy (upper tract urothelial cancer, bladder cancer, prostate cancer)
- renal calculi
- UTI
- nephrological causes
6
Q
investigations of painless visible haematuria
A
- MSU (rule out infection )
- U&E (renal disease)
- flexible cystoscopy (bladder tumour)
- CT urogram (renal and ureteric tumours + kidney stones)
- serum PSA (rule out prostate cancer)
7
Q
what else can can cause positive dipstick for haematuria or red coloured urine
A
pos dipstick: myoglobin
red coloured urine: beetroot, rifampicin, porphyrins
8
Q
pain and urology
A
kidney pain: fixed constant flank pain/ colicky pain superimposed on a constant dull pain
ureteric distention: loin to groin pain, colicky pain
9
Q
investigations of urology/kidney problems
A
- urine analysis: dipstick (protein:renal disorder, nitrites and leucocytes: infection), microscopy, culture, cytology
- blood tests, FBC, biochemistry, culture
- imagine: KUB, IV pyelogram, USS, MRI, angiography
10
Q
why do you use KUB X ray
A
calcification (renal and urinary tract stones)
11
Q
why do you use IV pyelography
A
assess: anatomy (nb of kidneys, ureters), drainage, function (of kidneys), access (for surgery)
12
Q
when do you use USS in urology/nephrology
A
assess kidney architecture
13
Q
when do you use CT scan in urology/nephrology
A
stones
after USS: staging of malignancy, kidney disease that was visible
14
Q
causes of urological stones
A
- metabolic 50% (type 1 renal tubular acidosis, hyperparathyroidism, cystinuria, sarcoidosis, Crohns disease)
- urological (outflow obstruction and lesions)
- infection
- immobilisation (resorption of bone)
15
Q
types of urological stones
A
- 75% calcium oxalate
- 10% struvite ‘staghorn’ (magnesium ammonium phosphate)
- 10% urate (radiolucent)
- 5% mixed calcium phosphate and calcium oxalate
- 1-2% cysteine stones
16
Q
management of urological stones
A
- increase fluid intake
- diet: reduce animal protein, sugar, Na, oxalate
- treat infection
- for urate stones: alkalinise urine
- medications (bendroflumethazide, allopurinol, penicillamine)
surgery:
- no need < 5 mm, lower ureter, no obstruction
- ESWL -> ureteroscopic -> percutaneous -> laparoscopu -> open operation
17
Q
types of kidney tumours
A
benign: angiomyolipomas, oncocytoma
malignant: renal cell carcinoma, transitional cell carcinoma
18
Q
renal cell carcinoma
- aetiology/ presentation
- clinical features
A
- male:female 2:1, ‘th-6th decades
- clinical features: triad haematuria, pain, mass + paraneoplastic syndromes + metastatic disease
- management: surgical for resectable disease or immunotherapy
19
Q
papillary necrosis
- risk factors
- complications
- management
A
- risk factors: paracetamol/NSAIDs, DM, sickle cell disease, infection
- complications: obstruction and pyelonephrosis
management: urgent drainage and antibiotic treatment
20
Q
ADPKD
- aetiology
- symptoms
- diagnosis
A
aetiology:
-autosomal dominant (PKD1, PKD2)
symptoms:
- loin pain/haematuria (cyst haemorrhage)
- loin/abdominal discomfort (size)
- subarachnoid haemorrhages (Berry aneurysm)
- hypertension, uraemia, anaemia
- liver, pancreas and spleen cysts
- mitral valve prolapse
diagnosis:
-ultrasound/ CT scan
management:
- BP control
- renal function monitoring
21
Q
von Hippel-Lindau disease
- aetiology
- clinical manifestations
- screening
A
aetiology:
- autosomal dominant, present within 2-3rd decade
clinical manifestations: cortical renal cyst, renal cell carcinoma, renal haemangioblastoma, renal cell adenoma, renal hemangioma, retinal angioma, CNS haemangioblastoma
screening:
-anual USS, CT abdo every 3 years
22
Q
renal colic differentials
A
renal stones pyelonephritis ectopic pregnancy, sorted ovarian cyst appendicitis, diverticulitis pancreatitis, cholecystitis ruptured AAA musculo-skeletal pain
23
Q
haematuria investigations protocols
A
> 45yo macroscopic haematuria w/out infection:
- blood tests (FBC, U&Es, PSA)
- flexible cystoscopy
- CT urogram or renal USS
> 45yo microscopic haematuria
- cystoscopy
- renal USS
<45yo macroscopic haematuria w/out infection
- cystoscopy
- upper tract imaging
<45 yo microscopic haematuria: nothing unless:
- increase urinary frequency and urgency: cystoscopy (+ renal function, BP, urine protein excretion)
- loin pain: non contrast CT (+ renal function, BP, urine protein excretion)
24
Q
name of upper urinary tract infection
A
pyelonephritis (kidney)
25
name of lower urinary tract infection
cystitis (bladder)
26
lower UTI presentation
```
dysuria
increase frequency, urgency
haematuria
suprapubic discomfort
burning pain
cloudy, smelly urine
```
27
upper UTI presentation
triad: vomiting, flank loin pain (usually unilateral), fever
```
symptoms of Lowe UTI
malaise
fever
rigs
loin/back pain
signs of septicaemia
vomiting
```
28
risk factors for UTI
female, sex, condoms, menopause, urinary stones, urinary tract malformation, catheter
29
investigations for UTI
- urine dipstick (presence of proteins, leucocytes, nitrites and blood)
- MSU sent for microscopy, culture and sensitivity analysis
- FBC
- CRP
- CT or USS (to exclude pyonephrosis with loin pain and pyrexia)
30
management of UTIs
- 3 day course of antibiotics (trimethoprim, cephalexin or nitrofurantoin)
- if pyelonephritis and pyrexia: 24-48h IV gentamicin or temocillin + 10 day course oral antibiotics
If recurrent UTIs (more than 3 episodes/year):
- treat with long term low dose prophylactic antibiotics OR
- post-coidal antibiotic tablet OR
- self start 3 day course antibiotic at onset of symptoms OR
- topical oestrogen cream (in postmenopausal women)
31
risk factor bladder cancer
increasing age, smoking, exposure to chemical (i.e. dye industry and rubber manufacture), analgesic misuse
32
bladder cancer presentation
- visible painless haematuria (but can also be microscopic)
| - irritative urinary symptoms/UTI that doesn't resolve w/ antibiotics
33
bladder cancer staging
- pta: tumour cells confined to epithelium
- cis (carcinoma in situ): aggressive cells confined to epithelium (flat tumour)
- T1: tumour cells in sub-epithelium connective tissue
- T2/3 tumour cells in bladder wall muscle
- T4: tumour cells in adjacent organs (prostate/uterus)
34
bladder cancer grading
1: least aggressive/most well differentiated histologically
2: intermediate
3: most aggressive/least well differentiated
35
bladder cancer treatment
- stage Cis, pTa: TURBT
- stage 1 + grade 3: BCG, may require radical cystectomy
- stage 2-4: radical cystectomy or radiotherapy
- metastatic disease: systemic chemotherapy
36
types of cells that line the bladder
transitional epithelium
37
what does international prostate symptoms score measure
measures severity of urinary symptoms:
- incomplete voiding
- frequency
- intermittency
- urgency
- weak stream
- straining
- nocturia
+quality of life due to urinary symptoms
38
BPH
- symptoms/signs
- treatment
-symptoms/signs: obstructive LUTS (hesitancy poor stream, postmicturition dribbling, frequency and nocturia), enlarged bladder, (overflow incontinence) enlarged smooth, firm, rubber prostate
treatment:
- alpha 1 blockers (tamsolisin, alfuzosin, doxazosin)
- 5 alpha reductase inhibitors (finastride, dutasteride)
- TURP
39
prostate red flags
```
overflow incontinence
renal impairement
haematuria
recurrent UTI
raised PSA
```
40
storage/irritative LUTS
frequency, urgency, nocturne, incontinence (urge), enuresis
41
voiding/obstructive LUTS
poor flow, hesitancy, intermittency, incomplete voiding, straining, dribbling, incontinence (overflow)
42
prostate cancer symptoms and signs
symptoms:
LUTS (obstructive and irritated)
pain (back, skeletal from metastasis)
fatigue, weight loss
signs:
-hard irregular gland in DRE
43
investigations for prostate cancer
- trans-urethral US + sampling prostatic biopsy/ template biopsy
- PSA> 10 ng/ml?
44
tumour grade prostate cancer
Gleason score (addition of 2 most common scores): scores of 3-5 are considered cancerous
Grade
1: Gleason score 6
2: Gleason score 7 (3 +4)
3: Gleason score 7 (4+3)
4: Gleason score 8
5: Gleason score 9/10
45
def pyuria
pus in the urine
46
functions of the kidney
```
A WET BED
Acid base balance
water removal
erythropoiesis
toxin removal
BP control
electrolyte balance
vit D activation
```
47
what criteria do you use for KDIGO guidelines for AKI staging
serum creatinine
| urine output
48
KDIGO guidelines for AKI staging
1: - SCr: 1.5-1.9x baseline Or >3.0 mg/dL increase
- urine output<0.5 ml/Kg/hr for 6-12h
2: -SCr 2-2.9 x baseline
- UO: <0.5 mL/Kg/hr for >12h
3: -SCr: >3.0x baseline OR >4.0 mg/dL OR initiation for RRT or <18 yo, eGFR <35 ml/min/1.73m2
- UO: <0.3 ml/KG/hr for >24h or anuria for >12h
49
pre renal causes of AKI
(reduced renal perfusion)
dehydration, sepsis, hypotension, shock, hepatorenal syndrome, severe HF, intra abdominal hypertension/compartment syndrome
50
renal causes of AKI
NSAIDS, ACEi, ARBs, gentamicin, GN/vasculitis, contrast, interstitial nephritis, myeloma, rhabdomyolysis
51
post renal causes of AKI
(obstruction)
| prostate enlargemen, renal stones, pelvic cancer
52
risk factors for AKI
```
>65 yo
history of AKI
CKD (eGFR <60)
symptoms/history of urological obstruction
diabetes, HF, liver disease
sepsis
hypovolaemia
oliguria
nephrotoxic drugs
exposure to iodinated contrast agents
```
53
ECG changes in hyperkalemia
peaked T waves
low flat P waves
broad QRS > 3 ss
54
hyperkalemia treatment
- protect the heart: IV calcium chloride or calcium gluconate
- shift K+ into cells: IV infusion of insulin-glucose + nebuliser salbutamol
55
diagnosis of AKI
-rise in serum creatinine
-fall in urine output
(try and measure against baseline)
56
what tests to do if you suspect an AKI
```
urine dipstick
urine cultures (UTI)
stool culture (for pathogens causing diarrhoea)
serum creatinine, eGFR
CXR
ECG
KUB ultrasound
```
57
management of AKI
- manage the cause
- maintain appropriate hydration
ONLY consider dialysis if:
- hyperkalaemia
- pulmonary oedema
- metabolic acidosis
- uraemic encephalopathy
is there anything else?
58
causes of acute tubular necrosis
- sustained under perfusion and reduced renal blood flow of renal tubules
- nephrotoxins
59
what are the 3 phases of ATN
oligouric phase: kidneys produce <500mls urin/day (patients vulnerable to fluid overload and electrolyte imbalance + creatinine levels rise rapidly)
maintenance phase: increased urinary output (helps maintain fluid and electrolyte balance + creatinine stabilises)
polyuric recovery phase: polyuria (can cause hypovolaemia + electrolyte loss + creatinine levels fall)
60
SEPSIS 6
in: antibiotics, oxygen, fluids
out: urine output, lactate, blood cultures
61
what are daily requirements of:
- water
- sodium
- potassium
- calcium
- magnesium
- chloride
- phosphate
- glucose
- water: 1.5 ml/kg/hr
- sodium/pottassium: 1 mmol/kg/24h
- calcium: 1000mg
- magnesium: 350 mg
- chloride: 750-900mg
- phosphate: 700mg
- glucose: 50g/day
62
why is it important to do an early morning midstream urine sample when testing for CKD?
due to orthostatic proteinuria: benign condition caused by periods of prolonged standing
63
what conditions can you have proteinuria?
```
after physical exercise
pregnancy
fever
abnormal high BP
UTI
nephrotic/nephritic syndrome
```
64
def pruritus
itchy skin
65
def of CKD
abnormalities of kidney function or structure > 3 months with implications to health :
-markers of kidney damage
-GFR <60 ml/min/1.73 m2
(on at least 2 occasions separated by period of 90 days)
66
def eGFR
creatinine based estimated of GFR
67
what are the metabolic complications of CKD
- CKD mineral bone disease (hypocalcaemia, hyperparathyroidism)
- renal anaemia
- metabolic acidosis
- hyperkalaemia
68
what are the treatments for the metabolic complications of CKD
- calcitriol/alphacalcidol
- EPO and IV iron
- oral alkali (ie sodium bicarb)
- dietary restrictions of potassium + reduce ACEi
69
what are the physical complications of CKD
fluid overload
70
what increases risk of CKD
```
-increases susceptibility:
age
family history
reduced kidney mass
low birth weight
ethnic minorities
low income
```
```
-direct kidney damage:
diabetes
high BP
autoimmune disease
systemic sepsis
UTI
urinary stones
urinary obstruction
drug toxicity
```
71
what are the criteria for referral to renal services:
| CKD 1-2
referral not required
72
what are the criteria for referral to renal services:
| CKD 3
routine referral if:
- microscopic hamaturia
- urinary PCR >45 mg/mmol
- unexplained anaemia
- abnormal K+, Ca, Pi
- systemic illness (ie SLE)
- uncontrolled BP
- fall in GFR > 5ml/min in 12/12
- fall in GFR >15% after ACEi/ARB
73
what are the criteria for referral to renal services:
| CKD 4
urgent referral
74
what are the criteria for referral to renal services:
| CKD 5
immediate referral
75
which drug should you avoid in diabetes and CKD
metformin if eGFR <30
76
what are indications to start renal replacement therapy
fluid overload
refractory hyperkalaemia
uraemia symptoms (nausea, confusion, weight loss, vomiting)
Year 3
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