Renal and Urogenital System Flashcards
(244 cards)
1
Q
Where does each diuretic act in the nephron?
A
- Loop diuretics - Na-K-2Cl cotransporter in the thick ascending limb, diminsihing the osmotic gradient for water reabsorption
- Thiazide diuretics - Blocks NaCl transports in the DCT, stopping sodium and water reabsorption
- Potassium sparing diuretics - Blocks NaK channels in the Collecting duct
2
Q
WHAT IS BPH?
A
Increase in epithelial (glandular)
and stromal (musculofibrous)
cell numbers in the periurethral area of the prostate
3
Q
What is the incidence of BPH?
A
Older men affected
4
Q
What are the symptoms of BPH?
A
Lower urinary tract symptoms (LUTS)
AND
Haematuria
Bladder stones
UTIs
5
Q
What tests would you do for BPH?
A
-
DRE
- Enlarged prostate
-
‘Rule out’ cancer
- PSA raised
- Transrectal USS ± biopsy.
-
Ultrasound (large residual volume, hydronephrosis)
- Visulise kidneys
-
MSU (midstream specimin of urine)
- Bacteria
6
Q
What are the management options for BPH?
A
-
Drugs
- 1st line - Alpha-blockers
- Tamsulosin, alfuzosin
- They Decrease smooth muscle tone (prostate and bladder).
- 2nd line - 5alpha-reductase inhibitors
- Finasteride
- Decreases testosterone’s conversion to dihydrotestosterone
-
Surgery
- Transurethral resection of prostate
7
Q
What are the side effects of alpha blockers?
A
- Dry mouth
- Weight gain
- Dizziness
- Hypotension
- Sexual dysfunction
8
Q
What is a requirement of BPH but not BPE?
A
Androgens.
9
Q
WHERE CAN YOU GET STONES?
A
Anywehere from collecting duct to external urethral meatus (EUM).
Upper urinary tract
Renal Stones
Ureteric Stones
Lower urinary tract
Bladder stones
Prostatic stones
Urethral stones
10
Q
What is the epidemology of urinary tract stones?
A
Common: lifetime incidence up to 15%
Peak age: 20–40yr
Male more than females
11
Q
Why do patients get stones?
A
Anatomical factors
Congenital (horseshoe, duplex)
Acquired (obstruction, surgery)
Urinary factors
Metastable urine, promotors and inhibitors
Calcium, oxalate, urate, cystine
Dehydration
Infection
12
Q
What symptoms can urinary tract stones cause?
A
- Asymptomatic
- Loin pain
- Renal colic
- UTI symtpoms
- Dysuria, stangury, urgency, frequency
- Recurrent UTIs
- Haematuria
- Visible and non-visible (85%)
13
Q
WHAT IS RENAL COLIC?
A
Pain resulting from upper urinary tract obstruction.
14
Q
Where are the three main places where stones get stuck?
A
- Pelvic brim
- Pelvi-ureteric junction
- Vesico-ureteric junction
15
Q
What are the symptoms of renal colic?
A
- Rapid, severe unilateral loin pain
- Unable to get comfortable - writhing
- Radiates to groin and ipsilateral testis/labia
- Associated nausea / vomiting
- Spasmodic / colicky, worse with fluid loading
16
Q
How do you investigate a renal colic?
A
Imaging
CT-KUB
Urine dip
Urine microscopy
U&Es
17
Q
How do you manage renal colic?
A
-
Pain relief
- Diclofenac or opioids; abxif infection suspected
-
Stones <5mm diameter
- 90%+ pass spontaneously
-
Stones >5mm diameter:
- Medical therapy (nifedipine or tamsulosin)
- Extracorporeal shockwave lithotripsy
- Percutaneous nephrolithotomy
-
If obstruction + infection
- Ureteric stent may be needed
18
Q
WHAT IS PROSTATE CANCER?
A
Cancer of the prostate
19
Q
What type of cancer is prostate cancer?
A
Adenocarcinoma
20
Q
What are the risk factors of prostate cancer?
A
- +ve family history
- Increased testosterone
21
Q
Where does prostate cancer occur in the prostate?
A
Occurs in peripheral zone of prostate
85% of tumours are multifocal
22
Q
How does prostate cancer spread and where does it spread to?
A
Spreads locally through prostate capsule
Metastasises to
Lymph nodes
Bone (sclerotic)
Lung, liver and brain
23
Q
What are the biomarkers for prostate cancer?
A
Tissue
Serum
Prostate-specific Antigen (PSA)
Prostate-specific membrane antigen (PSMA)
Urine
PCA3
Gene fusion products (TMPRSS2-ERG)
24
Q
What does PSA do, what happens in BPH?
A
Serine protease responsible for liquefaction of semen
Small amount of retrograde leakage
Detected in small quantities in the blood
25
What does PSA show in prostate cancer?
PROSTATE SPECIFIC not CANCER SPECIFIC
Elevated in benign prostate enlargement, urinary tract infection, prostatitis
26
What are the symptoms of prostate cancer?
Asymptomatic or nocturia
Hesitancy
Poor stream
Terminal dribbling, or obstruction
**_Weight loss ± bone pain suggests mets_**
27
How can you diagnose prostate cancer?
**_DRE_**
Hard and irregular
**_Prostate specific antigen (PSA)_**
Increased
**_Prostate biopsy_**
**_Transrectal ultrasound scan (TRUSS)_**
28
What is the gleeson score? What is the T score?
Cancer grading of prostate
Most common grade + highest grade
Grades 1 - 5
**_T staging_**
T1 Non palpable
T2 Palpable + confined to prostate
T3 Palpable + through capsule
T4 Palpable + invade other structures
29
What is the treatment for prostate cancer?
**_Surgery_** - radical prostatectomy
**_Radiotherapy_** - external beam
**_Observation_** - watchful waiting
30
What is the treatment for metastatic prostate cancer?
**_Anti-androgen therapy_**
1. **Synthetic GnRH agonist or antagonists**
GnRH agonists: e.g. Goserelin (Zoladex)
initially therapy is often covered with an anti-androgen to prevent a rise in testosterone
2. **Bicalutamide**
Non-steroidal anti-androgen
Blocks the androgen receptor
3. **Chemotherapy**
31
What condition are you more at risk of after radiotherapy for prostate cancer?
Colon, bladder, and rectal cancer
32
WHAT IS BLADDER CANCER?
Cancer of the bladder
33
What are the different types of bladder cancer?
Transitional cell carcinoma
**_Some are_**
Squamous cell carcinoma
Adenocarcinoma
34
What are some risk factors of developing bladder cancer?
1. Paraplegia
2. Smoking
3. Occupational (rubber, cable, textile, printing)
4. Drugs (phenacetin, aspirin, cyclophosphamide)
5. Bladder stones
35
How can bladder cancer present?
1. 85% painless VH (visible haematurtia)
2. Irritative voiding / recurrent UTI's (CIS)
36
How can you diagnose a bladder tumour?
1. **CT**
* Urogram is both diagnostic and provides staging
2. **Cytoscopy + Biopsy**
* Diagnostic
3. **Urine**
* Microscopy/cytology (cancers may cause sterile pyuria)
37
What are the different stages of bladder cacner?
Ta surface
T1 lamina propria, not hit the muscle
T2 hit the muscle
38
How can you treat bladder tumours?
**_T1_**
Surveillance
Transurethral resection of bladder tumour (TURBT) Transurethral cystoscopy + diathermy
+/- maintenance chemo
**_T2-3_**
Radical cystectomy
Chemo (either post-op or neoadjuvant)
Preserve bladder function – orthotopic bladder reconstruction or urostomy
**_T4_**
Palliative chemo/radio
39
WHAT IS RENAL CANCER?
Cancer of the kidney
40
What are the types of renal cancer?
**95% renal cell carcinoma (RCC)**
An adenocarcinoma
## Footnote
**TCC (transitional cell carcinoma) \<5%**
41
What is the epidemology of renal cancer?
**_Sporadically_**
One tumour
Older men
Smokers
**_Inherited_**
E.g. Von Hippel-Lindau disease
Younger men and women
Both kidneys
42
What are the symptoms of renal cancer?
1. Most found incidentally!
2. Haematuria
3. Flank pain
4. Mass
5. Weight loss
6. Paraneoplastic syndromes
43
What substances do the paraneoplastic syndromes in renal cancer release?
1. Erythropoetin - more red blood cells, polycythemia
2. Renin - Increase blood pressure
3. PTHrP
4. ACTH - cortisol
44
What does a tumour of the left kidney cause that the right doesn't?
Varicocles due to vein going into renal vein before IVC
45
How is renal cancer staged?
Using the TNM system.
T - Size, growth into nearby vein
N - Spread to lymph nodes
M - Degree of metastasis
46
How is renal cancer diagnosed?
1. **BP**
* Increased from renin secretion.
2. **Blood**
* FBC (polycythaemia from erythropoietin secretion);
* ESR; U&E, ALP (bony mets?).
3. **Urine**
* RBCS
* Haematuria
4. **Imaging**
* US; CT/MRI; IVU (filling defect ± calcification);
* **CXR (‘cannon ball’ metastases)**
47
What is the treatment of renal cancer?
1. Resection if localised
2. Partial nephrectomy
3. Radical nephrectomy
4. Biological therapies if metastasized
**_Molecular targeted therapies_**
VEGF receptor
Sunitinib, bevacizumab and sorafenib
48
WHAT ARE EPIDIDYMAL CYSTS?
Masses that lie above and behind the testis
Lie on the epididymus
49
When do epididymal cysts develop?
Usually develop in adulthood
50
What is the causes of epididymal cysts?
Unknown
**_Theroies_**
Blockage
Trauma
Inflammation
51
What do epididymal cysts contain?
Clear or milky (spermatocele) fluid.
Dead sperm cells
52
What are the symptoms of epidiymal cysts?
Epididymal cysts are the most common cause of scrotal swellings seen in primary care.
Features
1. Separate from the body of the testicle
2. Found posterior to the testicle
53
What are the tests for epidiymal cysts?
1. Usually discovered incidentally - physical exam
2. They trans-illuminate
3. Fluctuant - unstable
4. Ultrasound
54
What is the treatment of epidiymal cysts?
1. Usaully none
2. **Medications**
* NSAIDs
3. **Surgery**
* Spermatocoelectomy
4. **Aspiration and sclerotherapy**
* Draw fluid out and something put back in
55
WHAT IS A HYDROCELE?
Result of excessive fluid in tunica vaginalis (serous space surrounding testes)
56
What are the different types of hydrocoeles?
**_Primary_**
Associated with a patent processus vaginalis
Typically resolves during the 1st year of life
**_Secondary_**
Testis tumour/trauma/infection.
57
What are the symptoms for hydrocele?
Painless mass
**_Sometimes_**
Pain
Heaviness
58
What are the tests for hydrocele?
Painless smooth, non-tender, cystic sweeling
Ultrasound
Cannot palpate testis as located within the fluid collection
TRANSILLUMINATES
59
What are the managements for hydrocele?
Asymptomatic - Nothing
Symptomatic - Aspiration, resection
60
WHAT ARE VARICOCOELES?
Dilated veins of pampiniform plexus.
61
Which side of the testis of more affected by varicoceles?
Left side more commonly a effected.
62
Which is the cause of varicoceles?
Left side unknown
Right side venous obsturction from tumour
63
What are the symptoms of varicocele?
1. Dull ache
2. Bag of worms
3. Heavy
64
What are the tests for varicoceles?
1. Ultrasound with Doppler studies
2. Physical exam
* Valsalva monuver.
3. Semen analysis
65
What are the treatments for varicoceles?
Conservative
Surgical treatment
Vascular ablation or embolization
66
WHAT IS EPIDIDYMITIS?
Inflammation of the epidiymis.
Acute epididymitis mostly occurs in young males.
67
What is the epidemology of epididmytis?
Acute epididymitis mostly occurs in young males.
68
What are the causes of epididymitis?
E. coli
Chlamydia
Gonorrhea
69
What is the pathology of epididymitis?
Organisms may get to Epididymis by retrograde spread from prostatic urethra & seminal vesicles or less commonly, through blood stream.
70
What are the symptoms of epididymitis?
Severe scrotal pain
Fever
Swollen scrotal area
71
What are the tests for epididymitis?
1. Prehn's sign - lift testicules to see if pain improves, it DOES in epididymitis
2. Ultrasound - check for torsion
3. Urethral swabs
72
What is the treatment of epididymitis?
Doxycycline
If gonorrhoea suspected add
Ceftriaxone
Scrotal elevation
73
WHAT IS TESTICULAR CANCER?
Cancer of the testis
74
What are the different types of testicular cancer?
1. Seminomas (germ cell) – slow growing, classic appearance - betaHCG - cause gynocomastia
2. Non-seminoma
3. Sex cord (stromal)
4. Mixed
5. Lymphoma
75
What is the epidemology of testicular cancer?
The commonest malignancy in males aged 15–44
76
What are some risk factors for testicular tumours?
**Cryptochidism - undecended testicle**
Fhx - family history.
Previous testicular tumour.
Poorly understood.
77
What are the symptoms of testicular cancer?
80% painless lump in testis (hard/craggy, lies within testis, can be felt above).
Abdominal mass
HYDROCOELE
PAIN
METASTASES
78
What are some investigations for testicular tumour?
**Scrotal US**
**Biopsy**
**Tumour markers**
1. AFP alpha feta protein (1/2 life 5 days) - also liver cancer, secreted by placenta
2. B-hcg (24-48)
3. LDH - lactacte dehydrogenase - shows turnover of cells
79
What operations do you do for testicular tumour?
1. Early inguinal orchidectomy if malignant.
Types of tumour -
1. SEMINOMAS are very radiosensitive.
2. NON-SEMINOMAS (TERATOMAS) - cytotoxic chemotherapy.
80
WHAT IS ACUTE KIDNEY INJURY?
Rapid reduction in kidney function over hours to days
81
What are the risk factors for acute kidney injury?
1. Age \>75
2. Chronic kidney disease
3. Cardiac failure
4. Peripheral vascular disease
5. Chronic liver disease
6. Diabetes
7. Drugs (esp newly started)
8. Sepsis
9. Poor fluid intake/increased losses
10. History of urinary symptoms
82
What are the pre-renal causes of AKI?
Renal hypoperfusion,
Hypotension
Renal artery stenosis ± ACE-i.
83
What are the Intrinsic renal causes of AKI?
1. Glomerulonephritis
2. Acute tubular necrosis (ATN)
3. Acute interstitial nephritis (AIN), respectively
4. Rhabdomyolysis
5. Tumour lysis syndrome
84
What are the post renal causes of AKI?
Caused by urinary tract obstruction
Stones
Malignancy
Extrinsic compression
85
What are some nephrotoxic drugs?
1. **ACE inhibitors/ ARBs**
* Results in dilated efferent arterioles decreasing GFR
2. **NSAIDs**
* Inhibits cyclooxygenase which causes excess vasoconstriction of the afferent arteriole
3. Metofrmin
4. Diuretics
5. **Aminoglycosides (10-15% incidence of Acute Tubular Necrosis)**
6. **Digoxin**
86
What are the different stages of an AKI?
87
What is the presentation of AKI?
1. Oliguria or anuria
2. Nausea, vomiting
3. Dehydration
4. Confusion
5. Hypertension
6. Urinary retention (large painless bladder)
7. Postural hypotension
88
How can you assess AKI?
1. U&Es
2. Urinalysis
3. Imaging
* Renal ultrasound
89
How do you diagnose acute kidney injury?
1 OUT OF 3
1. Rise in creatine \> 26 micromol/L in 48 hrs (above baseline).
2. Rise in creatinine \> 50% (best figure in last 6 months).
3. Urine output \< 0.5 ml/kg/hr for \> 6 consecutive hours.
90
How can you treat AKI?
1. Euvolaemia
2. **Stop nephrotoxic drugs**
NSAIDs
Aminoglycosides
ACE inhibitors
Diuretics
Sometimes - Metofrmin, Lithioum + Digoxin
3. **Treat underlying cause**
4. **Manage complications**
5. **Dialysis**
* IF ENCEPHALOPATHY PRESENT
91
What are some complications of AKI?
1. Hyperkalaemia
2. Pulmonary oedema
92
What are the implications for dialysis in a patient with an AKI?
1. Severe metabolic acidosis
2. Persistent hyperkalaemia
93
WHAT IS GLOMERULONEPHRITIS?
Inflammation in the glomerulus.
94
What is the basic difference between nephritic and nephrotic syndrome?
Nephrotic syndrome involves the loss of a lot of protein
Nephritic syndrome involves the loss of a lot of blood
95
What are the consequences of glomerulonephritis?
Damage to the glomerulus restricts blood flow, leading to compensatory increased BP
Damage to the filtration mechanism allows protein and blood to enter the urine
Loss of the usual filtration capacity leads to acute kidney injury
96
What is the spectrum of glomerulonephritis disease?
1. **Blood pressure**
* Normal to malignant hypertension
2. **Urine dipstick**
* Proteinuria mild --\> nephrotic; haematuria mild --\> macroscopic
3. **Renal function**
* Normal to severe impairment
97
What are the causes of glomerulonephritis?
1. **Nephrotic**
* Membranous
* Minimal change
* Diabetes
* SLE (class V nephritis) Amyloid
* Hepatitis B/C
2. **Nephritic**
* IgA nephropathy
* Post streptococcal
* Vasculitis
* SLE (other classes of nephritis)
* Anti-GBM disease
98
WHAT IS NEPHRITIC SYNDROME?
**_Haematuria_**
+++ blood on urine dipstick (macro/microscopic)
Red cell casts (distinguishing feature)
**_Proteinuria_**
++ protein on urine dipstick
**_Hypertension_**
**_Low urine volume (\<300ml/day)_**
99
What are some causes of nephritic syndrome?
1. Post-streptococcal glomerulonephritis
2. IgA nephropathy
3. Rapidly progressive glomerulonephritis (Goodpasture’s syndrome/vasculitis disorders)
100
When does nephritic syndrome normally appear?
**_Often appears days-weeks after URTI_**
1. IgA nephropathy – days after URTI
2. Post-streptococcal glomerulonephritis – weeks after URTI
101
What are the clinical features of nephritic syndrome?
1. Haemoatruia
2. Proteinuria
3. Facial oedema
4. Hypertension
5. Oliguria
102
What is the treatment for nephritic syndrome?
1. Monitor fluid balance, weight, blood pressure and renal function
2. Restrict sodium and potassium as appropriate
3. Restrict fluids
4. Treat hypertension
5. Consider prophylactic penicillin
103
WHAT IS IgA NEPHROPATHY?
IgA accumulates in nephron and causes inflammation
Classically presents as macroscopic haematuria in young people following an upper respiratory tract infection.
104
What are the clinical features of IgA nephropathy?
1. Commonly young male
2. Macroscopic haematuria
105
How can you diagnose IgA nephropathy?
1. Biopsy
* Focal proliferative glomerulonephritis with IgA
106
What is the management of IgA nephropathy?
1. Supportive care: BP control with RAAS inhibitors, Diet, Lower Cholesterol.
2. Prednisolone (alternative-day regime)
3. Phenytoin - causes reduced IgA levels
107
WHAT IS NEPHROTIC SYNDROME?
1. Proteinuria
2. Hypoalbuminaemia
3. Oedema
108
What are the causes of nephrotic syndrome?
**_Primary_**
Minimal change disease
Membranous nephropathy
Focal segmental glomerulosclerosis
**_Secondary_**
Hepatitis
Diabetic nephropathy
Drug-related
109
What are the test for nephrotic syndrome?
Urine dip (protein +++)
Bloods (show low albumin)
Biopsy (adults)
110
What are the complications of nephrotic syndrome?
1. **_Susceptibility to infection_**
Loss of immunoglobulin in urine and also immunosuppressive treatments
2. **_Thromboembolism_**
Increase clotting factors and platelet abnormalities.
3. **_Hyperlipidaemia_**
Hepatic lipoprotein synthesis, response to low oncotic pressure
111
What is the treatment of nephrotic syndrome?
1. Steroids in children
2. Diuretics for oedema
3. ACE-i for proteinuria
4. Treat underlying cause
112
WHAT IS MEMBRANOUS GLOMERULONEPHRITIS?
Thickening of glomerular capillary wall.
IgG, complement deposit in sub epithelial surface causing leaky glomerulus
113
What are the different types of membranous glomerularnephritis?
Primary MN:
PLA2R antigen is the target antigen in 70-80% cases of primary MN.
Secondary MN:
Associated with autoimmune conditions, virsues, drugs and tumours.
114
What are the causes of membranous glomerularnephritis?
1. **Idiopathic**
* Due to anti-phospholipase A2 antibodies
2. **Infections**
* Hepatitis B, malaria, syphilis
3. **Malignancy** (in 5-20%): prostate, lung, lymphoma, leukaemia
4. **Drugs**
* Gold, penicillamine, NSAIDs
5. **Autoimmune diseases**
* Systemic lupus erythematosus (class V disease), thyroiditis, rheumatoid
115
What are the clinical features of membranous glomerularnephritis?
1. Proteinuria or nephrotic syndrome (80%)
2. Hypertension (10-50%) seems to depend on the amount of renal damage
3. Haematuria is rare
116
What is the diagnosis for membranous glomerularnephritis?
1. Renal biopsy
* The basement membrane is thickened with subepithelial electron dense deposits.
* Silver staining - this creates a 'spike and dome' appearance
117
What is the treatment for membranous glomerularnephritis?
1. All patients should receive an **ACE inhibitor** or an **angiotensin II receptor blocker (ARB)**:
* These have been shown to reduce proteinuria and improve prognosis
2. **Immunosuppression**
* Corticosteroids alone have not been shown to be effective. A combination of **corticosteroid + another agent such as cyclophosphamide** is often used
3. **Consider anticoagulation** for high-risk patients
118
WHAT IS MINIMAL CHANGE DISEASE?
Commonest cause of nephrotic syndrome in children
In adults it can be idiopathic or in association with drugs (NSAIDS) or paraneoplastic (usually Hodgkin’s lymphoma).
119
What is the pathology of minimal change disease?
1. T cells secrete inflammatory cytokines and damage foot processes on **podocytes**
2. Charge is lost
3. Albumin let through
4. Ig not let through
120
What is the presentation of minimal change disease?
1. Normal apart from
2. Nephrotic syndrome with selective proteinuria:
3. [albumin] \> [globulin]
4. Minimal or absent haematuria (never macroscopic)
121
What are the diagnosis options for minimal change disease?
1. Biopsy: **Normal under light microscopy (hence the name).**
2. Electron microscopy shows enhacement of the **podocyte foot processes**
122
What is the treatment of minimal change disease?
1. Majority of cases (80%) are **steroid-responsive**
2. **Cyclophosphamide** is the next step for steroid-resistant cases
123
WHAT IS CHRONIC KIDNEY DISEASE?
Impaired renal function for \>3 months based on abnormal structure or function, or GFR \<60mL/min/1.73m2 for \>3 months with or without evidence of kidney damage
124
What are the different stages of chronic kidney disease?
Only can call CKD if patient has symptoms and changes on urine dip
125
After what GFR stage are symptoms seen?
Symptoms usually only occur once stage 4 is reached (GFR \<30).
End-stage renal failure (ESRF) is defined as GFR \<15 mL/min/1.73m2 or need for renal replacement therapy (RRT—dialysis or transplant).
126
What are some causes of chronic kidney disease?
1. Glomerulonephritis - accounts for 25% of cases
2. **Multisystem disease:**
* Diabetes mellitus
* Acute pyelonephritis / tubulointerstitial disease
* Hypertension and vascular causes
127
What are the symptoms of chronic kidney disease?
1. Malaise
2. Loss of appetite
3. Insomnia
4. Nocturia and polyuria due to inability to concentrate urine
5. Anaemia
6. Peripheral and pulmonary oedema
128
What is the most useful sign of chronic kidney disease?
One of the most useful signs is bilaterally small kidneys on USS.
129
What must happen for diagnosis of CKD?
1. The renal failure must be demonstrated to be long-standing and not due to an acute and reversible renal insult
2. The aetiology of the renal damage should be determined
3. Any reversible factors should be identified and addressed
130
What is the most important differences between AKI and CKD?
1. Small kidneys on ultrasound for CKD
2. Hypocalcaemia due to lack of vit D in CKD
131
What is the treatment of CKD?
1. **Reduced dietary intake of phosphate** is the first-line management
2. IF ACR \>70
IF eGFR \<60 on two occasions
* Start ACE inhibitor and STATIN
3. Phosphate binders
4. Calcium binders e.g. calcium acetate
* May cause hypercalcaemia
5. Vitamin D:
* Alfacalcidol
* Calcitriol
6. Parathyroidectomy may be needed in some cases
132
What is acceptable once starting treatment for CKD?
Which levels can change and how much by?
1. NICE suggest that a decrease in eGFR of up to 25% or a rise in creatinine of up to 30% is acceptable, although any rise should prompt careful monitoring and exclusion of other causes (e.g. NSAIDs).
2. A rise greater than this may indicate underlying renovascular disease.
133
HOW IS ERECTILE FUNCTION CONTROLLED?
Erection is a neurovascular phenomenon under hormonal control
Arterial dilatation, smooth muscle relaxation, activation of the corporeal veno occlusive mechanism
134
What is erectile dysfunction?
The persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance
135
What is the aeitology of erectile dysfunction?
**_Organic_**
Vasculogenic
Neurogenic
Hormonal
Anatomical
Drug induced
**_Psychogenic_**
136
What are some common risk factors for erectile dysfunction?
In common with CVS disease
Lack of exercise
Obesity
Smoking
Hypercholesterolaemia
Metabolic syndrome
Diabetes x 3 risk of ED
137
How can you diagnose ED?
1. **Indicators of psychological aetiology**
2. **IIEF (International index for Erectile Function)**
Erectile function, orgasmic function, sexual desire, ejaculation, intercourse and overall satisfaction
3. **Physcial examination**
138
What are some indicators of psychological aetiology of ED?
1. Sudden onset of ED
2. Good nocturnal and early morning erections
3. Situational ED
4. Younger patient
139
What is Peyronies disease?
140
What labratory tests can you do for ED?
1. **Fasting glucose**
2. **Lipid profile**
3. **Morning testosterone**
* If low testosterone perform prolactin, FSH, LH
141
What are the treatment options for ED?
1. **PDE-5 inhibitors (such as sildenafil, 'Viagra')**
* They should be prescribed (in the absence of contraindications) to all patients regardless of aetiology
2. **Vacuum erection devices** are recommended as first-line treatment in those who can't/won't take a PDE-5 inhibitor.
142
What are some curable causes of ED?
1. **Hormonal causes**
* **Testosterone deficiency**
* Primary testicular failure
* Pituitary/hypothalamic failure
* **Testosterone replacement**
* Contraindicated if history of prostate cancer
* Check DRE and PSA beforehand
* Monitor for hepatic or prostatic disease
2. **Psychosexual counselling**
* Variable results
143
What is each line of treatment for ED?
**_First Line_**
Phosphodiesterase (PDE5) inhibitors e.g. Sildenafil (Viagra)
**_Second Line_**
Apomorphine SL
Intracavernous injections
Intraurethral alprostadil
Vacuum devices
**_Third Line_**
Consider penile prosthesis implantation
144
What are some common side effects from ED drugs?
Headache
Flushing
Dyspepsia
Nasal congestion
Dizziness
Visual disturbance
145
HOW IS CHLAMYDIA TRACHOMATIS TRANSMITTED?
**_Adult_**
Urethra
Endocervical canal
Rectum
Pharynx
Conjunctiva
**_Neonate_**
Conjunctiva
Atypical pneumonia also in neonatal CT
146
What are the symptoms for chlamydia?
1. Asymptomatic in around 70% of women and 50% of men
2. **Women**
* Cervicitis (discharge, bleeding), dysuria
3. **Men**
* Urethral discharge, dysuria
147
What is chlamydia diagnosis?
1. **Nucleic Acid Amplification Tests (NAAT)**
* High specificity and sensitivity
* Sensitivity not 100%
* Negative test ≠ not infected
2. **Female**
* Vulvovaginal swab
3. **Male**
* First void urine
148
What is the chlamydia treatment?
1. **Doxycycline -** 7 day course
2. If pregnany then azithromycin, erythromycin or amoxicillin
149
What are some chlamydia complications?
1. Epididymitis
2. Pelvic inflammatory disease
3. Endometritis
4. Increased incidence of ectopic pregnancies
5. Infertility
6. Reactive arthritis
7. Perihepatitis (Fitz-Hugh-Curtis syndrome)
150
HOW IS NEISSERIA GONORRHOEAE TRANSMITTED?
**_Adult_**
Urethra
Endocervical canal
Rectum
Pharynx
Conjunctiva
**_Neonate_**
Conjunctiva
Atypical pneumonia also in neonatal CT
151
What are the symptoms for gonorrhoea?
1. **Males**
* Urethral discharge, dysuria
2. **Females**
* Cervicitis e.g. leading to vaginal discharge
3. Rectal and pharyngeal infection is usually asymptomatic
152
What is the Gonorrhoea diagnosis?
1. **Microscopic examination of Gram stained smears**
* ****Genital secretions looking for gram negative diplococci within cytoplasm of polymorphs
* Male urethra
* Female endocervix
2. **Nucleic acid amplification tests (NAAT)**
* ****Men - First pass utine
* Women - vaginal or endocervical swab
3. **Culture on selective medium to confirm diagnosis**
153
What is the Gonorrhoea treatment?
**Ceftriaxone** IM
Partner notification
154
WHAT IS SYPHILIS?
Syphilis is a sexually transmitted disease which is characterised by:
minor early illness
more serious late manifestations after a variable latent period
155
How can syphilis be transmitted?
Safer sex – Men who have sex with men avoiding unprotected anal intercourse
BUT
Syphilis highly transmissible through oral sex
156
What are the symptoms of syphilis?
1. **Primary**
* Chancre leision - mostly genital
* Lymphadenopathy
2. **Secondary**
* Fever
* Sore throat
* Malaise
* Skin rashes
3. **Tertiary**
* Gummata - granulomatous lesions
157
How do you diagnose syphilis?
1. **Dark ground microscopy**
Detection of spirochaete in primary and secondary syphilis
2. **Serology**
- Treponema pallidum HaemAgglutination test (TPHA) - Always positive even after treatment
- Venereal Disease Research Laboratory (VDRL Test) - Negative after treatment
158
What is the treatment for syphilis?
Penicillin by injection is mainstay
Efficient follow up and partner notification essential
159
WHAT IS THE DEFINITION OF A UTI?
The presence of a pure growth of \>105 organisms per mL of fresh MSU
160
What are some UTI syndromes?
**_Lower tract_**
Cystitis
Prostatitis
Epididymitis/orchitis
Urethritis
**_Upper tract_**
Pyelonephritis
161
What is the classification of UTIs?
**_Asymptomatic bacteriuria_**
**_Uncomplicated_**
Normal renal tract + function
**_Complicated_**
Abnormal renal/GU tract, voiding difficulty/obstruction, decreased renal function, impaired host defences, virulent organism
**_Recurrent_**
Further infection with a new organism
**_Relapse_**
Further infection with the same organism
162
What is pyuria?
Presence of leucocytes in the urine
Associated with infection
Sterile pyuria
163
What is the most common pathogen for UTIs?
E.coli.
164
What are the signs and symptoms of UTIs?
Loin/abdopain
Offensive-smelling urine
Haematuria
Fever
165
How can you diagnose UTIs?
1. MC&S of MSU [GOLD]
2. Dipstick
3. Bloods
166
What can be investigated with Microscopy?
1. **White blood cells**
2. **Red blood cells**
3. **Casts**
* Give clues to renal pathology
* Can be indicative of infection
* Damage to kidney epithelium (glomerulonephritis)
4. **Bacteria**
5. **Epithelial cells**
167
What are the first line antibiotics for UTIs?
Avoid broad spectrum antibiotics
**_Nitrofurantoin_**
Pregnancy - avoid near term
Renal function
**_Trimethoprim_**
Pregnancy - teratogenic in first trimester and should be avoided during pregnancy
168
What are the risk factors for UTIs?
1. Female
2. Intercourse
3. Pregnancy
4. Menopause
5. UT obstruction
6. Malformations
7. Immunosuppression
8. Catheterization
169
WHAT IS CYSTITIS?
Cystitis is inflammation of the bladder, usually caused by a bladder infection
170
What are the symptoms of cystitis?
1. Frequency
2. Dysuria
3. Urgency
4. Haematuria
5. Suprapubic pain.
171
What are the investigations for cystitis?
1. Urine dipstick
2. Urine microscopy, culture and sensitivity
3. Biopsy
172
What is the treatment for cystitis?
Nitrofurantoin or Trimethoprim
Cefalexin if preggers
173
WHAT IS PROSTATITIS?
Inflammation/swelling of the prostate gland
174
What is the epidemology of prostatitis?
Affects 35-50% men
Common In men of all ages
175
What is the pathogenesis of prostatitis?
Ascending infection from the urinary tract
Haematogenous spread
Gram negative organisms
E.coli, proteus, Klebsiella
176
What are the symptoms of prostatitis?
1. Pain
2. Low back pain
3. Few urinary symptoms
4. Swollen or tender prostate
177
What is the diagnosis of prostatitis?
1. Urinalysis and MSU
2. Bloods including cultures
3. STI screen
4. Urodynamic tests
5. Imaging
6. TRUSS +/- CT abdo and pelvis
178
What is the treatment of prostatitis?
Trimethoprim OR
Nitrofurantoin
179
WHAT IS URETHRITIS?
Inflammation of the urethra
180
What is the cause of urethritis?
**Gonococcal urethritis**
“classic” form of infective urethritis
caused by Neisseria gonorrhoeae (1)
**Non-gonococcal urethritis** (NGU)
most often caused by either Chlamydia trachomatis or Mycoplasma genitalium
181
What are the symptoms of urethritis?
Painful/difficult urination
182
How is urethritis transmitted?
1. **Predominantly sexually transmitted**
* Gonococcal vs non gonococcal
* Chlamydia trachomatis
* Ureaplamsa urealyticum
* T.vaginalis
* M.genitalium
* HSV
183
How do you diagnose urethritis?
Microscopy of either urethral swab or first-void sample
Chlamydia trachomatis - nucleic acid amplification test (NAAT)
Gonorrhoea - urethral smear microscopy, NAAT and culture
184
What is the treatment of urethritis?
Requires sexual health referral
Treatment (Abx depends on cause)
Ceftriaxone - Gonorrhoea
Azithromycin - One off dose
Doxycycline - 7 day course
185
WHAT IS EPIDIDYMO-ORCHITIS?
Inflammatory process of the epididymis +/- testes
186
How does epididymo-orchitis present?
Presents with acute onset of pain and swelling
187
What is epididymo-orchitis caused by?
Sexually transmitted pathogens ascending from the urethra or non-sexually transmitted uropathogens spreading from the urinary tract.
188
What does pathogenesis of epididymo-orchitis depend on?
Pathogenesis depends on age and lifestyle
–Age \<35 – STI\>UTI
–Age \>35 – UTI\>STI
Take a sexual history
Elderly predominantly catheter related
189
What are the epididymo-orchitis aetiology?
190
What is epididymo-orchitis signs and symptoms?
Symptoms
Acute onset –usually unilateral scrotal pain +/- swelling
Urethritis symptoms
UTI Symptoms
Signs
Unilateral swelling and tenderness of epididymis +/- testes, urethral discharge, hydrocoele, erythema +/- oedema of scrotum, pyrexia
191
What are the investigations for epidiymo-orchitis?
1. Urethral swab: Gonorrhoeae
2. First pass urine (FPU)/ urethral swab for nucleic acid amplification test (NAAT) for N. gonorrhoeae and C. trachomatis
3. MSU: MC&S
192
What is the treatment for epididmo-orchitis?
Analgesia
**_Antibiotics - if organism unknown_**
**Ceftriaxone** 500mg intramuscularly single dose
PLUS **Doxycycline** 100mg by mouth twice daily for 10-14 days
Sexual abstinence
Supportive underwear
Contact tracing
193
What are the antibitotics for epididymo-orchitis?
**Sexually transmitted**
1. IM Ceftriaxone
2. AND Doxycycline Orally
For 14 days and refer to GUM
**Non sexually transmitted**
1. Ofloxacin or Ciprofloxacin
For 14 days
194
What is a disease you must rule out for epididymo-orchitis?
MUST RULE OUT TORSION
Any doubt = surgical scrotal exploration
Surgical emergency
Features suggestive of torsion
Short duration of pain
Associated nausea/abdo pain
Previous short duration orchalgia
195
WHAT IS TESTICULAR TORSION?
Testicular torsion happens when a spermatic cord becomes twisted, cutting off the flow of blood to the attached testicle.
196
What are the symptoms of testicular torsion?
Sudden onset of pain in one testis, which makes walking uncomfortable. Pain in the abdomen, nausea, and vomiting are common.
197
What are the signs of testicualr torsion?
Inflammation of one testis—it is very tender, hot, and swollen. The testis may lie high and transversely.
198
What are the tests for testicular torsion?
1. Tender testis retractecd upwards
2. Cremasteric reflex is lost
3. Elevation of the testis does not ease the pain (Prehn's sign)
199
What are the treatments for testicular torsion?
1. Urgent surgical exploration
* Untwist and fixation
* Orchidectomy
* Could return to scrotum
200
WHAT IS PYELONEPHRITIS?
Infection of the renal parenchyma and soft tissues of renal pelvis /upper ureter
201
What are the symptoms of pyelonephritis?
Classical triad
1. Loin pain
2. Fever
3. Pyuria
202
What is the most causative organism in pyelonephritis?
E. coli
203
What are the investigations for pyelonephritis?
**Mainly clinical**
1. Urinalysis
2. Bloods including cultures
3. X-ray - stone in upper tract
204
What is the treatment for pyelonephritis?
**Cefalexin - can give in pregnant women and children too**
OR
Ciprofloxacin
205
What are the pyelonephritis complications?
Sepsis
Renal abscess
Progression to chronic pyelonephritis
206
WHAT IS POLYCYSTIC KIDNEY DISEASE?
Polycystic kidney disease (PKD) is an inherited kidney disorder. It causes fluid-filled cysts to form in the kidneys.
207
What are the different types of polycystic kidney disease?
Dominant and recessive
208
What are the dominant gene mutations in PKD?
85% have mutation in PKD1 – reach ESRF by 50s
15% have mutation in PKD2 – reach ESRF by 70s
Family screening important - MRI
209
What do the PKDs do?
Polycystinsregulate tubular and vascular development in the kidneys but also in other organs.
210
What are the signs of polycystic kidney disease?
1. Excessive water and salt loss
2. Nocturia
3. Loin pain (due to renal haemorrhage, stones and UTIs)
4. Hypertension
5. Bilateral kidney enlargement
6. Gross haematuria following trauma
7. Renal colic due to clots
8. UTI and pyelonephritis may be presenting features
9. Renal stones are twice as common than in the general population
211
What are the tests for PKDs?
Ultrasound diagnostic criteria
At least two unilateral or bilateral renal cysts at age \<30 years
At least two cysts in each kidney between the ages of 30-59 years
At least four cysts in each kidney at age \>60 years
The diagnosis is supported by hepatic or pancreatic cysts
212
What are the treatment options for polycystic kidney disease?
1. **No cure**
2. Counselling and support for patients & family members
3. Monitor for disease progression
4. Treat hypertension, UTIs, stones, give analgesia
5. Dialysis for end-stage renal failure
213
What are the extra-renal manifesations of PKD?
1. liver cysts (70% - the commonest extra-renal manifestation): may cause hepatomegaly
2. berry aneurysms (8%): rupture can cause subarachnoid haemorrhage
3. cardiovascular system: mitral valve prolapse, mitral/tricuspid incompetence, aortic root dilation, aortic dissection
4. cysts in other organs: pancreas, spleen; very rarely: thyroid, oesophagus, ovary
214
WHAT ARE THE CAUSES OF TRASIENT OR SPURIOIUS NON-VISIBLE HAEMATURIA?
1. Urinary tract infection
2. Menstruation
3. Vigorous exercise (this normally settles after around 3 days)
4. Sexual intercourse
215
What are some causes of persistent non-visible haematruia?
1. Cancer (bladder, renal, prostate)
2. Stones
3. Benign prostatic hyperplasia
4. Prostatitis
5. Urethritis e.g. Chlamydia
6. Renal causes: IgA nephropathy, thin basement membrane disease
216
What are some causes of red/orange urine?
1. Foods: beetroot, rhubarb
2. Drugs: rifampicin, doxorubicin
217
What is used for testing haematuria?
1. Urine dipstick is the test of choice for detecting haematuria
2. Renal function, albumin:creatinine (ACR) or protein:creatinine ratio (PCR) and blood pressure should also be checked
3. Urine microscopy may be used but time to analysis significantly affects the number of red blood cells detected
218
What is the definition of non-visible haematuria?
1. Persistent non-visible haematuria is often defined as blood being present in **2 out of 3 samples** tested **2-3 weeks apart**
219
What are the criteria for 2 week wait referral to urology?
1. Aged \>= 45 years AND:
* unexplained visible haematuria without urinary tract infection, or
* visible haematuria that persists or recurs after successful treatment of urinary tract infection
1. Aged \>= 60 years AND have unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test
220
HOW SHOULD DIABETIC NEPHROPATHY BE INVESTIGATED?
1. Albumin:cfeatinine ratio
2. Early morning
221
What should diabetic patients be started on with a ACR\>3?
Ace inhibitor or angiotensin-II receptor antagonist
222
WHAT IS ACUTE INTERMITTENT PORPHYRIA?
1. Acute intermittent porphyria (AIP) is a rare autosomal dominant condition caused by a defect in porphobilinogen deaminase, an enzyme involved in the biosynthesis of haem.
2. The results in the toxic accumulation of delta aminolaevulinic acid and porphobilinogen.
3. It characteristically presents with abdominal and neuropsychiatric symptoms in 20-40-year-olds. AIP is more common in females (5:1)
223
What are the features of acute intermittent porpyria?
1. abdominal: abdominal pain, vomiting
2. neurological: motor neuropathy
3. psychiatric: e.g. depression
4. hypertension and tachycardia common
224
How do you dignose acute intermittent porphyria?
classically urine turns deep red on standing
raised urinary porphobilinogen (elevated between attacks and to a greater extent during acute attacks)
assay of red cells for porphobilinogen deaminase
raised serum levels of delta aminolaevulinic acid and porphobilinogen
225
What is acute intermittent porphyria?
1. Avoiding triggers
2. Acute attacks
* IV haematin/haem arginate
* IV glucose should be used if haematin/haem arginate is not immediately available
226
HOW DO YOU CALCULATE THE ANION GAP?
The anion gap is calculated by:
(sodium + potassium) - (bicarbonate + chloride)
A normal anion gap is 8-14 mmol/L
227
What are the causes of a normal anion gap acidosis?
1. gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula
2. renal tubular acidosis
3. drugs: e.g. acetazolamide
4. ammonium chloride injection
5. Addison's disease
228
WHAT ARE THE FEATURES OF ACUTE GRAFT FAILURE?
1. **Acute graft failure (\< 6 months)**
* usually due to mismatched HLA. Cell-mediated (cytotoxic T cells)
* usually asymptomatic and is picked up by a rising creatinine, pyuria and proteinuria
* other causes include cytomegalovirus infection
* may be reversible with steroids and immunosuppressants
229
WHAT ARE THE FEATURES OF HYPERACUTE REJECTION?
1. **Hyperacute rejection (minutes to hours)**
* due to pre-existing antibodies against ABO or HLA antigens
* an example of a type II hypersensitivity reaction
* leads to widespread thrombosis of graft vessels → ischaemia and necrosis of the transplanted organ
* no treatment is possible and the graft must be removed
230
WHAT ARE HYALINE CASTS AND WHEN ARE THEY SEEN?
1. consist of Tamm-Horsfall protein (secreted by distal convoluted tubule)
2. seen in normal urine, after exercise, during fever or with loop diuretics
231
WHAT IS ACUTE INTERSTITIAL NEPHRITIS?
Drug induced kdiney injury
1. Caused by
* Drugs: the most common cause, particularly antibiotics
* Penicillin
* Rifampicin
* NSAIDs
* Allopurinol
* Furosemide
* Systemic disease: SLE, sarcoidosis, and Sjögren's syndrome
* Infection: Hanta virus , staphylococci
232
What are the features of acute interstitial nephritis?
1. fever, rash, arthralgia
2. eosinophilia
3. mild renal impairment
4. hypertension
233
What are the investigations of acute interstitial nephritis?
1. Sterile pyuria
2. White cell casts
234
WHAT IS THE MOST COMMON CAUSE OF PEITONITIS SECONDARY TO PERITONEAL DIALYSIS?
Staph epidermidis
235
What is the best diuretic to treat asictes?
Spironolactone
236
WHAT DOES RENAL ARTERY STENOSIS SHOW ON RENIN:ALDOSTERONE?
High in both
237
WHAT IS RHABDOMYOLYSIS?
Rhabdomyolysis will typically feature in the exam as a patient who has had a fall or prolonged epileptic seizure and is found to have an acute kidney injury on admission.
238
What are some causes of rhabdomyolysis?
1. Long lie
2. Excessive exercise
3. Crush injuries
4. Burns
239
What are the investigations for rhabdomyolysis?
240
By what mechanism does rhabdomyolysis cause AKI?
Acute tubular necrosis
241
WHAT PRECAUTIONS SHOULD BE TAKEN AFTER A VASECTOMY?
1. Doesn't work immediately
2. Additional contraception must be used until tests reveal azoospermia
3. Semen analysis needs to be performed twice following a vasectomy before a man can have unprotected sex (usually at 16 and 20 weeks)
242
WHAT ARE THE CAUSES OF HYDRONEPHROSIS?
243
What are the investigations for hydronephrosis?
1. ultrasound - first-line: identifies presence of hydronephrosis and can assess the kidneys
2. IVU- assess the position of the obstruction
3. Antegrade or retrograde pyelography- allows treatment
4. if suspect renal colic: CT scan (majority of stones are detected this way)
244
What is the management of hydronephrosis?
1. Remove the obstruction and drainage of urine
2. Acute upper urinary tract obstruction: nephrostomy tube
3. Chronic upper urinary tract obstruction: ureteric stent or a pyeloplasty
