Renal and GU conditions Flashcards

Question

Renal cell carcinoma -What staging do you use? - What syndrome is associated? RF Pathophysiology Symptoms Investigations Treatment

Answer 1

A renal adenocarcinoma arising from the renal cortex (or tubules). RF - Smoking, males, >55 years PATHOLOGY Accounts for 80-90% of renal cancers 3 most common types: Clear cell carcinoma (80% of RCC) Papillary Chromophobe Associated with Von-hippel lindau syndrome — Caused by autosomal dominant mutation in the VHL gene, a tumour suppressor gene- increasing risk of renal and pancreas cysts SYMPTOMS Triad of: haematuria, flank pain and palpable mass + weight loss (possible anaemia due to reduced production of EPO - or can even lead to polycythaemia, depends on tumour's features) (Causes left sided varicocele in men- varicose veins in spermatic cord) INVESTIGATIONS 1st line - Ultrasound (abnormal renal mass/cyst) GS - Contrast CT scan of chest/abdomen/pelvis (Use robson staging or TNM staging) TREATMENT 1st line - surgery --> Nephrectomy

Answer 2

Most common paediatric renal cancer - Tumour of renal tubules and mesenchymal cells - Also called nephroblastoma - Seen in children under 5

Answer 3

Complication RCC can lead to a cannonball metastases in the lungs (by spreading to the renal vein --> IVC --> and lungs Paraneoplastic syndromes for renal cell carcinoma: When a tumour secretes things that cause syndromes Renal cell carcinoma releases: EPO - polycythaemia Renin - hypertension PTH like protein - hypercalcemia ACTH - Cushing's

Answer 4

Urothelial carcinoma of the urinary bladder (transitional cell carcinoma)- accounts for >90% of bladder cancers. RF- Smoking, occupational exposure to dues/paints/rubber - painter, hairdresser, mechanic working with tyres, >65 year old man (Aromatic amines - e.g. naphthylamine) PATHOLOGY SMOKING is the biggest risk factor for bladder cancer Although most bladder cancers are transitional cell carcinomas, But if a patient has schistosomiasis (parasitic disease), they are more likely to have squamous cell carcinoma (10%) Caused by chronic irritation of the bladder (cuboidal and columnar epithelium changes to squamous (metaplasia) → dysplasia and cancer) SYMPTOMS Painless haematuria Exposure to Aromatic amines - 2-naphtylamine retired dye factory worker/painter/hairdresser presenting with painless haematuria INVESTIGATIONS (urinalysis to confirm for presence of haematuria) GS - Flexible Cystoscopy - visualises bladder tumours (with possible biopsy) TREATMENT 1st line - Transurethral resection of bladder tumour with [possible] intravesical chemotherapy (gemcitabine) - to reduce risk of recurrence Medical - chemotherapy/radiotherapy

Answer 5

Adenocarcinoma (malignant tumour) situated in the peripheral zone of the prostate RF - >50 years, BRCA2, HOXBI3, black ethnicity, family history PATHOLOGY Most common cancer in males It relies on androgen hormones to grow (e.g. testosterone) Most commonly spreads to lymph nodes and bones (lumbar back pain) - haematogenous (can spread to liver, lung and brain also) SYMPTOMS LUTS Nocturia, urinary frequency, hesitancy, dysuria, haematuria + Systemic cancer symptoms - weight loss, fatigue, night pain + Bone pain (lumbar back pain) INVESTIGATIONS First line - Digital rectal examination Serum PSA levels (elevated) (Cancerous tumour feels hard, irregular, asymmetrical) GS - GS - transrectal ultrasound + biopsy Also grade tumour based on gleason score TREATMENT First line - Radical prostatectomy (for local cancer) For metastatic cancer --> 1) Hormone therapy (to deprive androgens) with either - Bilateral orchidectomy (Surgical removal of testes) - Goserelin (GnRH agonist) - it desensitises GnRH receptors eventually so they produce less LH and FSH 2) Radiotherapy (External beam radiotherapy)

Answer 6

PSA testing is unreliable with 75% false positives and 15% false negatives

Answer 7

RF - Cryptorchidism (undescended testis), family history, infertility, 20-34 years PATHOLOGY 95% arise from germ cells 5% is non germ cell tumour: Germ cell tumours: (cells producing gametes) Seminoma - (most common) or non seminoma (teratoma, yolk sac tumour - common in children under 3) Non germ cell tumours: leydig and sertoli cell tumours Common places for testicular cancer to metastasise to are: lymphatics, lungs, liver and the brain. (hematogenously) SYMPTOMS Painless lump in testicles, which does NOT transilluminate (patient may also have hydrocele?) INVESTIGATIONS First line - Doppler ultrasound test → testicular mass (90% diagnostic) Blood tests Serum alpha feto-protein - elevated in teratoma, yolk sac tumour Beta hcg - elevated in both seminoma an non seminoma (Lactate dehydrogenase) GS - biopsy and microscopy Seminoma- fried egg (large central nuclei surrounded by clear cytoplasm) (Staging CT scan to look for areas of spread and to stage the cancer) TREATMENT 1st line Radical (inguinal) orchidectomy (surgery to remove the affected testicle) (offer sperm storage) Adjuvant therapy (post surgery) Chemotherapy Radiation therapy

Answer 8

lymphatics, lungs, liver and the brain. (hematogenously)

Answer 9

Most commonly spreads to lymph nodes and bones (lumbar back pain) - haematogenous (can spread to liver, lung and brain also)

Answer 10

Blockage of urinary flow RF - BPH, urolithiasis (renal stones), medications e.g. alpha receptor agonists PATHOLOGY Obstructive uropathy can cause: 1) Urinary retention 2) Increased kidney, ureter and bladder pressure 3) Hydronephrosis - can lead to renal tubular atrophy, a dilated renal pelvis and also increases risk of infection --> ADDITIONALLY reduced renal function can lead to hyperkalemia which leads to arrhythmias and possible death. SYMPTOMS - LUTS - Distended bladder - Inability to urinate - Costovertebral angle tenderness (kidney stones/obstruction) - Haematuria INVESTIGATIONS First line - Renal ultrasound GS maybe Magnetic Resonance Urography? - shows obstruction and anatomical abnormalities e.g. stones/tumours TREATMENT First line - Relieve kidney pressure --> Insert catheter, insert ureteral stent Then treat underlying cause e.g. BPH, stones, infection

Answer 11

A genetic condition characterised by development of multiple cysts within the renal tubules. (leads to bilateral enlargement and damage) RF- Family history of ADPKD, family history of cerebrovascular event PATHOLOGY There are 2 types: Autosomal dominant (more common) and autosomal recessive ADPKD Most commonly affected genes: PKD1 on CHROMOSOME 16 (more common-85%), PKD2 on chromosome 4. PKD1 and 2 code for polycystin, a protein found in the cilia of renal epithelial cells involved in cellular interaction and coding for voltage gated calcium channels, Mutation would result in abnormal signalling and formation of fluid filled cysts. SYMPTOMS Bilateral flank/back/abdominal pain Hypertension Haematuria Abnormal polycystine Can lead to extra renal manifestations: Circle of willis - Berry aneurysm (which can rupture → subarachnoid haemorrhage) Hepatomegaly - liver cysts INVESTIGATIONS 1st line - Renal ultrasound (enlarged kidneys with cysts) Genetic testing - PKD1/2 mutation TREATMENT No curative treatment 1st - Lifestyle modification - smoking cessation, regular exercise 1st line drug treatment --> Tolvaptan for slowing down development of cysts and progression of renal failure If patient is hypertensive - Ace inhibitors If patient reaches end stage renal disease → Renal transplant first. (If cannot, dialysis)

Answer 12

Abnormal polycystin Can lead to extra renal manifestations: Circle of willis - Berry aneurysm (which can rupture → subarachnoid haemorrhage) Hepatomegaly - liver cysts Pancreatic cysts

Answer 13

Abnormal dilation of the internal testicular veins and pampiniform plexus (that drains blood from the testis) PATHOLOGY Pampiniform plexus drains into the testicular vein. It plays a role in regulating the temperature of blood entering the testes by absorbing heat and cooling blood in the testicular artery. Main causes: Which results in blood flowing back from the testicular vein into the pampiniform plexus. - Increased hydrostatic pressure in the left renal vein - as left pampiniform plexus inserts into the left renal vein at a right angle (rather right pampiniform plexus which joins the IVC) - Incompetent/congenitally absent valves (incompetent valves within the left testicular vein) SYMPTOMS Painless scrotal mass described like a bag of worms (More prominent on standing) INVESTIGATIONS Clinical diagnosis In patients with a small scrotum/obese patients --> Doppler ultrasound can be used TREATMENT No treatment--> reassure patient Surgery only required if varicocele is severe

Answer 14

Cysts that occur at the head of the epididymis (Extratesticular cyst - above and behind testis) Cyst - Abnormal sacs of fluid SYMPTOMS Scrotal mass is not transilluminated (because of fluid) - but the CYST itself is transuilluminated (Soft round lump, typically at the top of the testicle) INVESTIGATION 1st line + GS - Scrotal ultrasound TREATMENT Conservative treatment - no treatment needed, reassurance If they cause pain, discomfort or infertility then consider surgical removal

Answer 15

It helps to differentiate between a hernial swelling and a true scrotal swelling. If you can get above the lump/swelling on squeezing --> true scrotal swelling If unable to get above --> hernia

Answer 16

A collection of fluid within the tunica vaginalis RF - Infants <6 months, infants whose testes descend late PATHOLOGY The tunica vaginalis is a sealed pouch of membrane surrounding the testes (and is part of the peritoneal membrane → during development of the fetus, it is separated from the peritoneal membrane and remains in the scrotum partially covering each testicle) Can be idiopathic or can be secondary to: Testicular torsion Trauma Epididymo Orchitis SYMPTOMS Scrotal mass that may enlarge with activity due to increased abdominal pressure --> fluid flows into scrotal sac TRANSILLUMINATION (because of fluid) INVESTIGATIONS GS - Scrotal ultrasound Serum HCG to exclude testicular cancer TREATMENT Mostly observation, only if hydrocele gets large and uncomfortable then surgical repair is definitive treatment

Answer 17

A urological emergency caused by the twisting of the testicle on the spermatic cord leading to constriction of the vascular supply, time sensitive ischaemia, and necrosis of testicular tissue. RF - <25 years, neonate, trauma, bell clapper deformity PATHOLOGY Causes: -- Bell clapper deformity - most common anatomical defect (testicle is freely mobile within the tunica vaginalis) - testes are lying horizontally instead of vertically -- Can be triggered by activity e.g. sport, trauma SYMPTOMS Rapid onset unilateral testicular pain Abdominal pain Nausea and vomiting NO PAIN RELIEF WITH ELEVATING TESTES Loss of cremasteric reflex INVESTIGATIONS 1st Ultrasound to check testicular blood flow (if there is increased risk - do a surgical exploration rather than ultrasound) TREATMENT (Surgical exploration) then Urgent surgery (within 6 hours) - Testicular detorsion

Answer 18

The involuntary loss of urine RF - Obesity, increasing age, pregnancy (mostly females) PATHOLOGY and SYMPTOMS 2 types 1) Stress incontinence - Due to weakness of the pelvic floor and sphincter muscles. Therefore urine leaks at times of increased intra abdominal/bladder pressure. Caused by: sneezing, laughing, coughing (increases abdominal pressure), pregnancy and obesity, 2) Urgency incontinence - Due to overactivity of the detrusor muscle of the bladder - urgency to pass urine and have to rush to the bathroom, sometimes not arriving before urination occurs. INVESTIGATIONS Cough stress test? To see if it is stress incontinence TREATMENT Stress incontinence 1st line - Lifestyle modifications --> Avoid caffeine, supervised PELVIC FLOOR EXERCISES Last resort - Surgery Urgency incontinence 1st line- Lifestyle modifications- Limit caffeine and alcohol 1st line drug treatment - Anticholinergic medication - oxybutynin (blocks muscarinic receptors on the detrusor muscle)

Answer 19

Chronic urinary retention due to obstruction to the outflow of urine RF- MEN PATHOLOGY Loss of ability to pass urine even when bladder is full (500ml). --> Result in an overflow of urine. Can be due to: - Benign prostatic hyperplasia - Renal stones - Neurological conditions - multiple sclerosis, diabetic neuropathy - Pelvic tumours (Anti cholinergic medication) TREATMENT - Catheterisation

Answer 20

Painful inflammation within the prostate (Chronic is symptoms lasting more than 3 months) RF - UTI, BPH PATHOLOGY Commonly caused by organisms entering the prostate from urinary tract infections. Especially E.coli SYMPTOMS Chronic prostatitis - presents with at least 3 months of Pelvic pain - which can affect the perineum, testicles and scrotum LUTS - FUNI SHID Sexual dysfunction Acute is above + Fever Chills Myalgia Malaise Warm, soft boggy prostate gland INVESTIGATIONS 1st - Urinalysis/urine dipstick - leukocytes Urine microscopy, culture and sensitivity - for bacteria (mostly E.coli) Digital rectal examination - Prostate is warm, boggy (wet and mushy to the touch) TREATMENTS Acute Without sepsis Oral antibiotics - Ciprofloxacin Consider: NSAIDS - Ibuprofen for pain relief Chronic prostatitis - Alpha blockers (tamsulosin)

Answer 21

FUNI SHID Storage (FUNI) - Frequency - Urgency - Nocturia - Incontinence Voiding (SHID) - Weak, intermittent stream - Hesitancy - Incomplete emptying of bladder - Terminal dribbling

Answer 22

Cefalexcin

Answer 23

Ureteropelvic junction Ureterovesical junction Pelvic brim (when ureter crosses over iliac vessels)

Answer 24

NCCT - Kidney stones, trauma, strokes Contrast CT - blood vessels, organs or tissues with increased vascularity/perfusion.

Answer 25

IgA nephropathy

Answer 26

Genetic defect in type 4 collagen (X-linked most common) Triad of Hereditary nephritis, sensorineural deafness, ocular abnormalities (cataracts, etc)

Answer 27

Antistreptolysin O Titre and low C3

Answer 28

HPV 16 and 18

Answer 29

Stop the DAMN drugs - Diuretics (and digoxin) - Ace inhibitor/ARB - Metformin and methotrexate - NSAIDs

Renal and GU conditions Flashcards

(53 cards)