Renal and urology Flashcards
(70 cards)
1
Q
What cancer is aniline a RF for?
A
bladder cancer
2
Q
What is the pathogen most common associated with haemolytic uraemic syndrome?
A
E. coli strain O157
3
Q
what are the characteristic features of haemolytic uraemic syndrome?
A
microangiopathic haemolytic anaemia (MAHA)
acute renal failure (AKI)
thrombocytopenia
4
Q
What are the symptoms of haemolytic uraemic syndrome?
A
profuse diarrhoea which turns bloody 1-3 days later
abdominal pain
reduced urine output
haematuria
nausea
fever
malaise
swelling/oedema
5
Q
differentials for scrotal lumps
A
- Scrotal skin
- Sebaceous cyst
- Melanoma
- Intra-vaginal
- Hydrocele
- Epididymal cyst
- Epididymitis
- Hernia
- Torted hydatid
- Intra-testicular
- Orchitis
- Testicular abscess
- Testicular cancer
- Lymphoma
- Other
- Sarcoma of the cord
- Lipoma of the cord
6
Q
causes of visible haematuria (UROLOGY)
A
- Bladder cancer
- Infection
- Simple UTI
- Schistosomiasis
- TB
- Urinary tract calculi
- Prostatic bleeding
- Trauma
- Upper tract transitional cell carcinoma
- Renal cancer
- Prostate cancer
- Radiation cystitis
7
Q
causes of transient or spurious non-visible haematuria
A
- urinary tract infection
- menstruation
- vigorous exercise (this normally settles after around 3 days)
- sexual intercourse
8
Q
causes of persistent non-visible haematuria
A
- cancer (bladder, renal, prostate)
- stones
- benign prostatic hyperplasia
- prostatitis
- urethritis e.g. Chlamydia
- renal causes: IgA nephropathy, thin basement membrane disease
9
Q
how many stages of AKI are there?
A
3
10
Q
describe stage 1 AKI
A
- Creatinine ↑ > 26 micromol/L within 48 hours OR
- Creatinine risk of 50-99% of baseline within 7 days (1.5-1.99 x baseline) OR
- Urine output < 0.5 ml/kg/hour for > 6 hours
11
Q
describe stage 2 AKI
A
- 100-199% creatinine rise from baseline within 7 days (2-2.99 x baseline) OR
- Urine output < 0.5 ml/kg/hour for > 12 hours
12
Q
describe AKI stage 3
A
- > 200% creatinine rise from baseline within 7 days (> 3 x baseline) OR
- Creatinine rise to > 354 micromol/L with acute rise of > 26 micromol/L within 48 hours or > 50% within 7 days OR
- Urine output < 0.3 ml/kg/hr for 24 hours or anuria for 12 hours
13
Q
what are the indications for dialysis?
A
- Indications AEIOU
- Acidosis - severe metabolic acidosis with pH < 7.2
- Electrolyte imbalance - persistent hyperkalaemia > 7mM
- Intoxication - poisoning
- Oedema - refractory pulmonary oedema
- Uraemia - encephalopathy or pericarditis
14
Q
where does BPH hyperplasia occur? histological features
A
hyperplasia in transitional zone
increase in stromal: epithelial ratio
15
Q
Ix for BPH
A
- bedside
- DRE
- urinalysis
- bloods
- PSA + UE&s
- imaging
- bladder scan, USS KUB if concern of hydronephrosis
- specialist
- international prostate symptoms score (IPSS)
- urodynamic studies
16
Q
management of BPH
A
-
Conservative
- Mild disease can watch-and-wait strategy
- Bladder training - less effective if LUTS + proven outlet obstruction
- reduce caffeine, ETOH, Tx constipation
-
Medical
-
Alpha adrenoceptor antagonist
- Alpha blocker e.g doxazosin, tamsulosin
- ↓ smooth muscle tone, quick effect
-
5-alpha reductase inhibitor
- e.g. finasteride
- If prostate > 30g or PSA >1.4 ng/ml + high risk of progression
- prevents dihydrotestosterone formation → ↓ prostate volume
- longer onset
-
Dual therapy
- Moderate-severe LUTs and prostate > 30g or PSA > 1.4ng/ml
-
Alpha adrenoceptor antagonist
-
Surgical
- Indicated - severe sx, refractory
- surgical resection to reduce prostate mass
17
Q
what are the surgical options for BPH?
A
- TURP
- Transurethral incision of prostate (TUIP) if prostate < 30g but symptomatic
- REZUM - steam vapour to shrink prostate, 30-80g prostate, IPSS > 13
- HoLEP - holmium laser enucleates prostate, useful in very large prostates
- Urolift - staples back lateral lobes of prostate, useful in young as ↓ retrograde ejaculation
- Radical prostatectomy - prostate > 80g
18
Q
types of bladder cancer + most common
A
- Transitional cell carcinoma (urothelial carcinoma, 90%)
- Adenocarcinoma
- Squamous cell carcinoma - associated with schistosomiasis
- Sarcoma
19
Q
Ix for bladder cancer
A
-
Bedside
- Urinalysis + MC&S
-
Bloods
- FBC, U&Es, ALP
-
Imaging
- CT urogram
- multiparametric MRI - staging, indicated before TURBT
- USS KUB - usually 1st line if non-visible haematuria
-
Specialist or scoring
- Flexible cystoscopy - diagnostic
-
Transurethral resection of a bladder tumour (diagnostic or curative, must obtain detrusor biopsy)
- NICE - white-like guided TURBT with photodynamic diagnostics
20
Q
2ww rules for bladder CA
A
- > 45 + unexplained visible haematuria w/o UTI
- > 45 + visible haematuria that persists/recurs after UTI treatment
- > 60 + unexplained non-visible haematuria and dysuria/↑ WCC
21
Q
bladder cancer management
A
-
non muscle invasive
- low risk - TURBT single intravesible mitomycin C
- intermediate - TURBT + 6 course intravesical mitomycin
- high risk - intravesical chemo or radical cystectomy
- f/up with cytoscopy
-
muscle invasive
- neoadjuvant cisplatin chemo
- radical cystectomy or radial radiotherapy
-
locally advanced or metastatic
- cisplatin combination chemotherapy
- pembrolizumab (if PD-L1 +ve)
22
Q
NICE definition of CKD
A
CKD should be diagnosed if any of the following met for more than 3 months(NICE):
- Markers of renal damage are present such as:
- Urinary ACR > 3mg/ml
- Urine sediment abnormalities
- Electrolyte or tubular disorders
- Abnormality on histology
- Structural abnormality on imaging
- History of transplant
- Persistent reduction in renal function with serum eGFR < 60
23
Q
give the impairment of water balance seen in CKD and Sx + signs
A
Fluid overload, hypervolaemia
signs and symptoms
- Pleural effusions (SOB, cough)
- Pedal or sacral oedema
- Ascites
- Reduced urine output due to poor filtration
24
Q
give the impairment of electrolyte homeostasis seen in CKD and Sx + signs
A
Hyperkalaemia
Cardiac dysrhythmias, palpitations
25
what is the excretion of waste impairment of function in CKD and presentation
**uraemia**
## Footnote
Pruritis, pericarditis, encephalopathy
26
what is the acid-base disturbance in CKD + PC
**acidosis**
N+V, tiredness
27
what is the **endocrine** disturbance in CKD and PC
* **Normocytic anaemia**
* Tired, SOB, pallor, headaches, LOC, chest pain, weakness, HF
* **Hypocalcaemia**
* Tetany, secondary hyperparathyroidism (Brown's tumours, adynamic bone turnover), osteomalacia/osteoporosis
* **Hypertension**
28
complications of CKD
* ESRF, AKI (acute-on-chronic)
* HTN, dyslipidaemia (e.g. secondary to nephrotic syndrome), **CVD risk** ↑ (renal osteodystrophy
* anaemia
* bone pain/fragility #, renal osteodystrophy (osteoporosis, necrosis + pathological #)
* Peripheral neuropathy and myopathy incl. paraesthesia, sleep disturbance, restless leg syndrome
* Malnutrition (ESRF) - poor intake + hypoalbuminaemia
29
management of CKD conservative
* *Diet* **-** dietary advice and dietician input as required for potassium, phosphate, calorie + salt intake
* *Psychological support*
* *Medication review*
30
medical management of CKD
* *Blood pressure control* - managing HTN
* ACR \< 70mg/mmol target BP \< 140/90 mmHg
* ACR \> 70mg/mmol target BP \< 130/80 mmHg
* 1st line
* ACR \> 30mg/mmol → ACEi or ARB
* If DM ACEi/ARB if 3mg/mmol
* ACR \< 30 mg/mmol → following NICE pathway for HTN
* *Managing proteinuria*
* **ACEi/**ARB if DM ACR \> **3mg**/mmol OR non-diabetic + non-HTN ACR \> **70mg**/mmol
* SGLT2 inhibitors offered to T2DM as dual therapy if ACR \> 30mg/mmol + criteria eGFR met
* *Managing cardiovascular risk*
* Statins - 20mg for prevention
* *Optimise other health conditions*
31
surgical management of CKD
renal transplant
32
management of CKD CoD - anaemia
* Treat concurrent hyperparathyroidism
* Optimise iron status
* oral iron if not on haemodialysis
* IV infusion if inadequate response in 3 months or on haemodialysis
* Erythropoietin stimulating agents
33
management of CKD CoD - hyperkalaemia
* Acute management as per hyperkalaemia guidance
* **Patiromer** - potassium binder within GI tract
* Emergency acute life-threatening alongside standard care
* Stage 3b-5 with CKD or HF and persistent ↑ K+ confirmed as \> 6, not taking RAAS inhibitors and not on dialysis
34
management of CKD CoD - hyperphosphataemia
* Dietary managing under dietician
* Phosphate binder if stage 4/5 not dialysis
* 1st line = **calcium acetate**, SE - ↑ Ca2+
* Parathyroidectomy is rarely required
35
most common pathogens for epidiymitis-orchitis
* \< 35 → STI (chlamydia, gonorrhoea)
* \> 35 → non-sexually transmitted e.g. gram negative bacteria (E.coli, pseudomonas)
36
management of epididymis-orchitis
**Conservative**
* Advise scrotal support
* Advise to abstain from sex is ?/confirmed STD till Tx complete
**Medical**
* NSAIDS - anti-inflammatory + analgesic
* Empirical anti-microbial therapy - 2-4 weeks
* \< 35 years old - **doxycycline** 100mg/12 hour to cover chlamydia + treat partners
* Ceftriaxone 500mg/12h if suspected gonorrhoea
* \> 35 → treat for gram-negative
* Re-assess after 3/7
**Surgical** - rare, if torsion can't be excluded, abscess drain
37
features of nephrotic syndrome
**Nephrotic syndrome**
* *Proteinuria (\>3.5g/24h)*
* *low serum albumin (\<24g/L)*
* *oedema*
38
features of nephritic syndrome
*HTN + proteinuria + haematuria*
39
common causes of nephrotic syndrome
* **primary**
* Membranous
* Minimal change
* FSGS
* Mesangiocapillary GN
* **secondary**
* Diabetes
* SLE
* Amyloid
* Hepatitis B/C
40
common causes of nephritic syndrome
* **primary**
* IgA nephropathy
* Mesangiocapillary GN
* **secondary**
* Post streptococcal
* Vasculitis
* SLE
* Anti-GBM disease
* Cryoglobulinaemia
41
IgA nephropathy vs post-streptococcal glomerulonephritis
IgA nephropathy → days after URTI
post-strep → weeks after URTI
42
management of hydroce==
**Congenital**
* Reassure hydrocele likely to resolve by 2 years
* Refer if concern of underlying path., concurrent inguinal hernia, localised to spermatic cord, palpable abdominal mass
**Adult**
* Urgent USS if 20-40 years of age and testis cannot be palpated
* *Conservative* - watch and wait
* *Surgical*
* Must exclude CA prior to Tx
* Aspiration - symptomatic relief, only frail + sx
* **Lord's repair** - folding of tunica vaginalis, inguinal approach
* **Jaboulay's repair** - eversion of the sac
* Recommended for secondary non-communicating
* Scrotal approach
43
types of renal stone
* **calcium oxalate (MAJORITY, 85%)**
* radio-opaque
* high Ca2+ in urine = RF
* **calcium phosphate** (10%)
* radiopaque, RTA
* **cysteine**
* **uric acid** (5-10%)
* radiolucent, associated with haemolysis/tissue breakdown
* **struvite**
* Mg + ammonium + phosphate
* urease bacteria → chronic UTI
* _staghorn_
44
what is the type of stone that typically causes staghorn calculus?
struvite
45
Ix for renal calculi
* **Bedside**
* Abdominal examination
* Urine dipstick - haematuria
* **Bloods**
* Renal function and U&Es
* FBC + CRP _+_ cultures - ?infection
* Serum calcium - assess if contributing cause
* **Imaging**
* **Non contrast CT KUB** - diagnostic imaging of choice
* Urgent, within 24 hours of presentation
46
management of renal stones
**Conservative**
* Watchful waiting - stones \< 5mm, no sx of obstruction
**Medical**
* Analgesia
* 1st line - NSAIDs, **PR/IM diclofenac (75mg diclofenac IM)**
* 2nd line - IV paracetamol
* Consider opioids
* **Alpha blockers** - **tamsulosin**, alfuzosin
* Indications - distal stone \< 10mm
**Surgical**
* ***Percutaneous nephrolithotomy***
* Indicated: stones _\>_ 2 cm, complex stones (staghorn, cysteine)
* Retrograde ureteral catheter, cystoscopy, stone collected
* ***Ureteroscopy***
* 1st line for _distal/middle ureteric stone_s, pregnant women
* ***Shock wave lithotropsy***
* ***Open stone surgery***
* \<1% o
* Indications: failed Tx, complex/staghorn calculi, morbid obesity, complex renal/ureteric anatomy
47
when to admit someone with renal stones?
* Shock or signs of systemic infection
* ↑ risk of AKI e.g. pre-existing CKD or solitary/transplanted kidney or bilateral stones suspected
* Dehydrated and not tolerating oral fluids
* Uncertainty of diagnosis
48
General management of nephrotic syndrome
General for adults 1. Sodium and fluid restriction 2. Diuretic treatment - furosemide 3. High dose steroids part of Tx for most. Good response in kids, less predictable in adults ACEi - can be used in less treatment-responsive adults
49
management of overactive bladder
* **conservative**
* bladder training - 6/52
* fluid management
* pelvic floor exercises 8 TDS, 3/12
* **medical**
* anticholinergics - oxybutynin, tolterodine
* mirabegron - beta-3 adrenergic agonist, 2nd or dual
* **surgical**
* neurotoxin botulinum toxin A
* neuromodulation - perc. _sacral_ or post. tibial nerve stimulation
* augmented cystoplasty
* urinary diversion (urostomy)
50
types of polycystic kidney disease
* **type 1 - AD, adult**
* Ch16 (85%) - ESRF by 50s
* Ch4 (15%) - ESRF by 70s
* 1 in 1000
* **type 2 - AR, children**
* rare
* Ch6, early presentation with renal + hepatic cysts
51
histological types of prostate cancer
* adenocarcinoma (most common, peripheral zone)
* TCC
* SCC
* small cell prostate cancer
52
RF for prostate cancer
* **Non-modifiable** = African ethnicity, FHx +ve, BRCA mutation, ↑ age
* **Modifiable** = Obesity, smoking, diet (high in animal fats and milk products)
53
2WW for prostate cancer
Indicated:
* DRE reveals hand, nodular prostate
* PSA \> 3 nanogram/mL and ages 50-69
54
Ix for prostate cancer
* **Bedside**
* **Digital rectal examination**
* Urine dipstick
* **Bloods**
* **PSA:**
* Normal 0-4
* 50-69 and if \> 3nanogram/mL refer via 2WW
* bone profile (including calcium)
* FBC, U&Es, acid phosphatase, LFTs, U&Es
* **Imaging**
* **CT/MRI + isotope bone scan:** staging
* **Multiparametric MRI** only if for radical treatment
* **Specialist or scoring**
* **Transrectal USS + needle biopsy:** abnormal cells in 2 different samples → malignancy diagnosis
55
management of prostate cancer
* **low risk, Gleason \< 7**
* active surveillant
* radical prostatectomy
* radical radiotherapy
* **intermediate + local. 8+**
* hormone therapy
* radical prostatectomy
* radiotherapy
* docetaxel chemotherapy
* **metastatic**
* hormonal treatment
* GnRH agonist + 3/52 anti-androgen
* goserelin
* anti-androgen - flutamide, cyproterone acetate
56
what is the gleason score?
* prostate cancer
* histology is graded from 1-5 from 2 biopsies and added together
* _\<_ 6 is low, 7 - intermediate, _\>_ 8 is high risk
57
causes of renal artery stenosis
* atherosclerosis
* fibromuscular dysplasia (\< 50)
* VTE
* compression by external mass
58
types of renal cell cancer
* **clear cell (70%, most common)**
* epithelial renal tumour with clear cell sets in capillary network
* associated with VHL
* **papillary (15%)**
* epithelial tumour of papillae _+_ tubules
* **chromophobe RCC**
* well circumscribed brown tumour
59
what is the histological type of RCC associated with long-term dialysis?
papillary
60
management of RCC
* **localised**
* resection - partial if \< 7cm, radial otherwise
* _+_ chemotherapy _+_ radiotherapy
* **advanced or metastatic**
* radial nephrectomy + biological treatment
* interferon alpha, IL2
61
management of stress incontinence
* **conservative**
* pelvic floor exercise 8 TDS, 3 months
* fluid intake
* reduce weight, optimise DM, Oestrogen if post-M
* **medical** - 2nd line, non surg. candidate
* duloxetine
* desmopressin - nocturia specifically
* **surgical**
* colposuspension
* autologous rectus fascial sling
* intramural bulking agents
* artificial urinary sphincter
62
types of testicular cancer
* ***Germ cell tumour (95%)***
* **Seminoma** (50%)
* ↑ HCG _+_ lactate, or normal
* **non-seminoma -** AFP and beta-HCG usually raised
* Teratoma
* Embryonal carcinoma
* Yolk sac tumour
* Choriocarcinoma
* Mixed seminoma-teratoma
* ***Non-germ cell tumour*** **(5%)**
* Sertoli
* Leydig
* Sarcoma
* Non-Hodgkin's lymphoma
63
Ix for testicular cancer
* **Bedside**
* Scrotal examination
* **Bloods**
* Serum beta-HCG
* Serum alpha fetoprotein
* Serum lactate
* Basics - FBC, U&Es
* **Imaging**
* **Scrotal USS** - visualisation of mass
* CT CAP - assessment for metastases
* CXR - assess for mets, cannonball
* **Specialist or scoring**
* **Sperm banking**
\*don't biopsy as risk of seeding, automatic upgrade of stage
64
management of testicular cancer
* **Radical orchidectomy _+_ lymph node dissection + prosthesis**
* _Inguinal orchidectomy_ (not scrotal)
* **+ chemotherapy**
* Chemotherapy = **mainstay**
* Indicated: higher stage disease (metastatic), high risk
* Low risk - **carboplatin** regime
* High risk - **BEP** combination (bleomycin, etoposide, platinum - cisplatin), usually 3 cycles
* **_+_ radiotherapy** - external beam radiation
65
summary of testicular cancer management
66
what is a varicocele?
Abnormal dilation of the internal spermatic veins and _pampiniform plexus_ which drains into the testis.
67
what side is a varicocele more common?
More common on the left due to the angle at which the left testicular vein meets left renal vein means there are no effective valves and therefore ↑ reflux from compression of renal vein by SMA and aorta
68
Ix for varicocele?
* **Bedside**
* Scrotal examination
* **Bloods**
* Serum FSH and testosterone
* **Imaging**
* Doppler USS - confirms diagnosis
* **Specialist or scoring**
* Semen analysis - if presenting with concurrent fertility concerns, common cause of subfertility
* RCC screen if rapid onset/older/Sx CA
69
management of varicocele
* **Conservative**
* If mild, aSx, normal semen analysis
* Observation
* **Referral to secondary care** - if:
* Sudden onset \> 40 years of age and remains tense on lying down - _urgent_
* Single right-sided varicocele - _urgent_
* Uncertainty about diagnosis
* Routinely causing pain or discomfort
* In adolescents consider
* **Surgical**
* aim to ligate veins to prevent abnormal flow
* Open or laparoscopic repair - ligation of vessels affected
* Percutaneous embolisation
70
complications of TURP
T - TURP syndrome
U - urethral stricture/ UTI
R - retrograde ejaculation
P - perforation of the prostate
