renal and urology Flashcards
(125 cards)
1
Q
define BPH
A
benign prostatic hyperplasia is an enlarged prostate compressing against the urethra increasing resistance => causing changes to the bladder => urinary frequency/urgency + reduced urine flow
2
Q
pathophysiology of BPH
A
dihydrotestosterone binds to androgen receptor on prostate => increased stromal / epithelial cells => ENLARGED prostate
- increased urethral resistance
- increased detrusor pressure to maintain urine flow (can lead to reduced detrusor contractility/ instability)
3
Q
causes of BPH
A
unknown but link to age-related hormonal changes (androgens)
4
Q
presenting symptoms of BPH
A
Lower urinary tract symptoms
- Frequency
- Urgency
- Nocturia
- Dysuria (burning)
- Hesitancy
- Incomplete voiding
- Poor stream
- Smell/ odour
- incontinence
Haematuria
5
Q
Examination findings of BPH
A
- enlarged prostate on digital rectal examination
- palpable distended bladder
- Ballotable kidneys
- Phimosis- narrow foreskin
- Meatal stenosis- narrowing of urethral opening
6
Q
Investigations + findings for BPH
A
- urinalysis (midstream urine => MC&S test)
- blood test (check for prostate-specific antigen rule out prostate cancer, U&Es)
- Flow rate + PVR (post-void residual) high PVR= obstruction
- bladder diary (fluid intake/ outake)
Imaging
- USS KUB if impaired renal function, loin pain, hematuria, renal mass on examination
- transrectal ultrasound
- flexible cystoscopy
7
Q
Management of BPH
A
- Mild symptoms => conservative (watchful waiting, lifestyle changes)
Medical (before surgery)
- selective alpha adrenergic antagonists (relax smooth muscle of internal urinary sphincter and prostate capsule)
- 5-alpha reductase inhibitors (less testosterone => dihydrotestosterone conversion- reduce prostate size)
Surgery
- transurethral resection of prostate
- transurethral incision of prostate
- open prostatectomy
8
Q
When would you treat BPH with catheterisation?
A
acute urinary retention (EMERGENCY)
- sudden inability to pass urine + SEVERE PAIN
9
Q
side effects of alpha adrenergic antagonists (e.g. tamulosin)
A
lowers bp => light headed
dry ejaculation
10
Q
Complications of BPH
A
- recurrent UTIs
- acute/chronic urinary retention
- urinary stasis
- bladder diverticuli
- stones
- obstructibe renal failure
- post-obstructibe diuresis
11
Q
prognosis for BPH
A
- mild symptoms usually controlled with medication
- most patients get relief from surgery
12
Q
define testicular torsion
A
twisting of spermatic chord => venous outflow obstruction of testes => arterial occlusion => infarction
SURGICAL EMERGENCY
13
Q
Types of testicular torsion
A
- intravaginal- spermatic chord twists within tunica vaginalis
- extravagina (neonates)- spermatic chord + tunica vaginalis twist
14
Q
causes of testicular torsion
A
- testes haven’t descended properly
- high investment of tunica vaginalis
15
Q
Differentials for testicular torsion
A
- epididymo-orchitis (older, gradual onset) => rule out with doppler sound
- incarcerated inguinal hernia
16
Q
presenting symptoms of testicular torsion
A
- SUDDEN hemiscrotal pain (in one testes)
- difficulty walking
- nausea + vomiting
- abdominal pain (RLQ/LLQ)
17
Q
examination findings of testicular torsion
A
- swollen, hot, tender testes
- one slightly higher/ horizontal
- thickened chord
- necrotic on transillumination
18
Q
Investigations for testicular torsion
A
- Doppler imaging of testes (can see arterial inflow - reduced in testicular torsion)
*arterial inflow increased in epididymo-orchitis
BUT SHOULD NOT DELAY SURGERY
19
Q
management of testicular torsion
A
- exploration of testes (<6hrs) and twists back into place
- bilateral orchidopexy - sutures testicles to scrotum to prevent further twisting
- If testes is necrotic => orchidectomy (remove testes)
20
Q
complications of testicular torsion (3 Is)
A
- infarction
- infection
- infertility
- atrophy
21
Q
define testicular cancer
A
malignancy of the testes
- seminomas 30-40 (mix of tumour cells and lymphocytes)- spreads via lymphatics => para-aortic nodes
- non-seminomatous germ-cell tumours (teratomas- spread to lungs via bloodstream) 20-30
- gonadal stromal tumours (rare)
22
Q
Risk factors for testicular cancer
A
- mal/undescended testes (cryptochidism)
- ectopic testes
- atrophic testes
23
Q
presenting symptoms of testicular cancer
A
- dragging/ heavy feeling in testes (disomfort)
- testes swelling
- firm irregular lump in testes
- back pain (para-aortic lymph node enlargement)
- lung metastasis (SOB, haemoptysis)
24
Q
examination findings of testicular cancer
A
- painless, hard mass on testes
- secondary hydrocoele
- lymphadenopathy (para-aortic/ supraclavicular lymph nodes)
- gynaecomastia (tumour produces b-HCG)
25
investigations for testicular cancer
Bedside:
- urinalysis
- pregnancy test (could be +ve due to b-HCG from tumour)
Bloods:
- FBC
- LFTs
- U&Es
- tumour markers: **b-HCG (choriocarcinomatous), alpha fetoprotein (teratomas), LDH** (non-specific) *placental alklaine phosphotase (seminatous component)*
Imaging:
- **_US of testes_**
- CXR- check for lung metastasis
- Staging CT CAP
26
Management for testicular cancer
**seminomas** (early stage) =\> _radical inguinal orchidectomy_ (remove spermatic chord + testes) + **radiation** =\> para-aortic lymph nodes
**teratoma** =\> _radical inguinal orchidectomy_ + chemo
Monitor AFP + staging CT CAP
late stage =\> palliative chemo
27
Define UTI
urinary tract infection usualy \>10^5 of organisms per ml
28
Classification of UTI
* lower UTI- urethraitis, cystitis (bladder), prostatitis (prostate)
* Upper UTI- pyelonephritis (kidneys)
* Uncomplicated UTI - normal renal tract + function
* Complicated UTI- abnormal renal tract + function (voiding, reduced renal function)
29
Risk factors for UTIs
* female (shorter urethra)
* sex
* pregnancy
* immunocompromised
* menopause
* Urinary tract obstruction/ malformation
* catheterisation
* exposure to spermacide
30
Pathogenic Causes of UTIs
* **_E.coli_**
* Staph. saprophyticus
* proteus mirabilius
* Enterococci
In immunocompromised
* klebsiella
* canadida albicans
* pseudomonas aeruginosa
31
Presenting symptoms of
1. Cystitis (LUTI)
2. Prostatis (LUTI)
3. Pyelonephritis (UUTI)
1. frequency, urgency, dysuria, haematuria, suprapubic pain
2. flu-like, lower backache, swollen prostate, less urinary symptoms
3. High fever, rigors, vomiting, loin pain, oligouria (AKI)
32
Examination findings of UTI
* fever
* foul smelling urine
* loin/ suprapubic pain
* enlarged prostate (prostatitis)
* enlarged bladder (cystitis)
33
Investigations for UTIs
Bedside:
* urine dipstick (*FIRST LINE*) =\> +ve leucocytes + nitrates
* **_Midstream urine test (MSU)_**=\> MC&S (*gold standard)*
* *Microscopy=\> +ve leucocytes = infection*
* *Culture = \>10^5 growth per ml*
Bloods
* FBC
* U&Es- check renal function
* CRP
* blood culture (exclude urosepsis)
*
Imaging
* USS of kidneys ureter bladder
34
Management of UTIs
* empirical antibiotics (trimethoprim/ NITROFURANTOIN) for lower UTI
* 3-6 days in women (longer for men)
\*Alternative: Co-amoxiclav, cefalexin
* Can give prophylaxis antibiotics for recurrent infections
* IV/PO co-amoxiclav (for uncomplicated non pregnant upper UTIs)
35
Complications of UTI
* pyelonephritis
* sepsis
* AKI
* renal abscess
* pyonephrosis
36
Define urinary tract calculi
crystals depositing in the urinary tract
* pelviureteric junction
* pelvic brim
* vesicoureteric junction
37
Types of ureteric stones
* calcium oxalate (most common)- hypercalceuria, IBD
* struviate- protos bacteria infection, staghorn stones
* uric acid- GOUT, leukaemia (high cell turnover)
* hydroxyapatite
* cysteine
* calcium phosphate - hyperparathyroidism (high Ca2+)
38
causes of urinary tract calculi
* idiopathic
* metabolic (hypercalceuria, hyperuraecemia, hyperoxaluria, renal tubular acidosis, hyperparathyroidism=\>hypercalcemia)
* infection (hyperuraecemia, recurrent UTIs)
* drugs (Idinavir, diuretics, antacids, corticosteroids)
* abnormalities (hydronephrosis, narrow pelviureteric junction)
* foreign objects (catheters, stents)
39
Risk factors for urinary tract calculi
* diet high in oxalate (chocolate, nuts, rhubarb, strawberrries, spinach)
* low fluid intake
* high sodium diet/ low pottasium diet =\> promote stone formation
* seasonal (high Vit D)
* horseshoe kidney (congenital)
40
Presenting symptoms of urinary tract calculi
* can be asymptomatic
* SUDDEN SEVERE intermittent/colicky flank pain
* may radiate- loin=\> groin pain (RENAL COLIC)
* Unable to lie still
* haematuria
* urinary frequency, urgerncy, retention
* nausea/ vomiting =\> as pain is severe
41
Examination findings of urinary tract calculi
* loin =\> groin tenderness
* * no signs of peritonitis
42
Investigations for urinary tract calculi
Bedside
* Urine dipstick (***first line*)**
* Pregnancy test
* Urine MC&S
Bloods
* U&Es - check renal function
* CRP
* FBC
* urate/ bone profile/ phosphate =\> hyperparathyroidism
* clotting
Imaging
* **_non-contrast CT KUB_** =\> look for stones, AAA, bowel pathology (***gold standard*)**
* USS of KUB (in pregnant women)
43
Management of urinary tract calculi
Acutely
* analgesia (PR diclofenac/ IM or opioids)
* Bed rest
* IV fluids
* monitor urine to check if stone has come out
Remove stone
1. \<5mm from LUT most pass out in urine (hydration/analgesia)
2. \>5mm/ pain doesn't reduce =\> medical expulsion with nifedipine/ alpha blockers (tamulosin)
3. 48hrs later =\> urethroscopy, ESWL, keyhole surgery (percutaneous nephrolithotomy)
Treat cause
* Allopurinol (hyperuraecemia)
* Parathyroidectomy (hyperparathyroidism =\> hypercalcemia)
Lifestyle
* increase fluid intake
**_Obstruction +infection (EMERGENCY)_**=\> decompress with nephrostomy
44
Describe Extra-corporeal shock-wave lithotripsy (ESWL)
electromagnetic shockwaves to break up stone into fragments so can pass in urine
45
Describe process of urethroscopy
* Insert scope up bladder =\> ureter to find stone
* Bag/ laser to break up stone
* If stone can't be retrieved put a **_JJ stent_** to avoid urinary tract obstruction
46
Complications of urinary tract calculi
* INFECTION- Pyelonephritis
* Sepsis
* Urinary retention
47
Complications of invasive treatment for urinary tract stones
* urethroscopy=\> perforation, fasle passage
* ESWL =\> pain, haematuria
48
define bladder cancer
malignancy of bladder cells (80% mucosa, 20% penetrate muscle)
* **Transitional cell carcinomas** (most common)
* Squamous cell carcinoma
Grade 1 = differentiated
Grade 2= intermediate
Grade 3= poorly differentiated
49
risk factors for bladder cancer
* **smoking**
* cyclophosphomide (chemo)
* chronic cystitis
* shistomiosis (chronic inflammation) =\> squamous cell carcinoma
* aromatic amines (rubber, dye)
* pelvic irradiation
50
presenting symptoms of bladder cancer
* **PAINLESS macroscopic haematuria**
* some urinary symptoms (frequency, urgency, nocturia)
* recurrent UTIs
51
investigations for bladder cancer
* urine dip
* MUS =\> MC&S
Imaging
* **cytoscopy + biopsy** (look at bladder + diagnostic)
* Ultrasound
* IV Urogram
* CT/MRI staging
52
Management of bladder cancer
Non-muscle invasive (early)
* low risk =\> TURBT (transurethral resection of bladder tumour during cystoscopy) + chemo
* medium risk =\> Chemo
* high risk =\> TURBT + BCG variant + cystectomy
Muscle invasive
* **Cystectomy** (remove bladder)
* Radiotherapy with a radiactive sensitiser
53
Side effects of radiotherapy
* cystitis
* diarrhoea
* hair loss
* tightening of vagina (painful sex)
* erectile dysfunction
* vomiting
54
Describe Transurethral resection of bladder tumour
* under general anaesthetic + insert cytoscope into bladder
* cut out tumour
* cauterise and close wound with mini-electric current
* urinary catheter
*
55
Describe nephrotic syndrome
damage to podocytes leading to
* proteinurea
* hypoalbuminanaemia
* oedema
* hypercholesterolemia
56
Causes of nephrotic syndrome
Primary
* **_minimal change glomerulonephritis_** (kids)
* membranous glomerulonephritis
Secondary
* **_diabetes mellitus_** =\> diabetic nephropathy
* SLE
* Sickle cell
* Drugs (NSAIDs)
* Alport syndrome
* HIV
* Hepaitis C/E
* malignancy
57
Presenting symptoms of nephrotic syndrome
* swelling of face, arms, legs, genitals
* family history of atopy, renal disease
* symptoms of causes (SLE =\> fatigue, joint pain, rashes)
58
Examination findings of nephrotic syndrome
* oedema (periorbital, peripheral, genital)
* ascites (shifting dullness, fluid thrill)
59
Investigations for nephrotic syndrome
Bedside
* urine dipstick (proteinurea)
* MUS =\> MC&S
Bloods
* FBC
* U&E
* LFT- low albumin
* glucose
* ESR/CRP
* lipid profile
Identify cause
* SLE autoantibodies (ANA, anti-dsDNA)
* Infections (HBV serology, malaria blood culture)
* Good pastures - anti-glomerular basement antibodies
Imaging
* renal ultrasound - exclude renal perforation
Renal biopsy
60
Management of nephrotic syndrome
Treat cause and complications
* anti-hypertensives
* angiotensin II receptor blocekers
* diuretics
* statins
* anti-coagulants
* corticosteroids (immunosuppressants)
Lifestyle
* less fat/cholesterol in diet
* low sodium
* reduce fluid intake
61
define epididymitis (epididymis) and orchitis (testes)
inflammation of epididymis and testes
* usually associated with each other
62
Causes of epididymo-orchitis
INFECTIVE origin
* \<35- **_Chlamydia_**
* \>35 - Kleibsella, enterobacter
* Viral = **Mumps**
* Fungal - canadidas (if immunocompromised)
IDIOPATHIC
63
Risk factors for epididymo-orchitis
* diabetes
* vasculitis
64
Presenting symptoms of epididymo-orchitis
* painful, swollen,tender testes
* difficulty waking
* acute onset (not as acute as torsion)
* penile discharge
* dysuria
* fevers/ sweating
* ***Ask aboout Sexual history*** - (chlamydia)
*
65
Examination findings of epididymo-orchitis
* swollen, tender testes
* testes is erythematous/ oedematous
* painful eliciting cremasteric reflex
* painful walking
* pyrexia
66
Investigations for epididymo-orchitis
Bedside:
* urine dipstick - check for UTI
* early morning urine collection (MC&S)
Bloods
* FBC- raised WCC
* raised CRP
* U&Es
Other
* increased blood flow on Duplex scan
67
Management of epididymo-orchitis
ANALGESIA + ANTIBIOTICS (2-4 weeks)
* \<35 (STI-related) = antibiotics (DOXYCYCLINE), gonnorrhoea (ceftriaxone)
* \>35 (non-STI related) = antibiotics (CIPROFLOXACIN)
Surgical
* lapratomy exploratio of testes if torsion can't be clinically excluded
* drainage if signs of abscess
68
Complications of epididymo-orchitis
* PAIN
* abscess
* fournieres gangrene
* mumps orchitis =\> testicular atrophy/ infertility
*
69
define inguinal hernia
protrusion of viscus through weakness in abdominal wall
70
features of an inguinal hernia
* can't get above lump (from abdomen could be hydrocoele)
* superior/medial to pubic tubercle
* reducible
* cough impulse =\> hernia appears
* direct hernias reduce on pressing at mid-point of inguinal ring
71
define incarcaerated hernia
obstructed hernia gets stuck due to bowel obstruction narrowing hernial orifice so bowel can't contents can't pass through
72
features of incarcerated inguinal hernia
* hard
* irreducible
* can't be ellicted by cough impulse
73
define strangulated inguinal hernia
blocked blood supply to bowel loops =\> ischaemia + infarction
74
features of strangulated hernia
* signs of peritonitis (rigid, rebound tenderness, guarding)
75
Treatment of incarcerated inguinal hernias
* oxygen, IV fluids, cannula, NGT, urinary catheter
76
what is acute kidney injury (AKI)
sudden minor/major loss of kidney function measured by increased serum creatinine/ low urine output
- usually due to less blood flow to kidneys (complication of another serious illness more common in elderly)
77
causes of AKI
* **SEPSIS**
pre-renal
* hypovolemia (bleeding, XS vomiting, diarrhoea, DEHYDRATION),
* low cardiac ouput (surgery/ cardiogenic shock)
intrinsic renal
* nephrotoxic drugs
* interstitial nephritis
post-renal
* renal stones
* prostate enlargment=\> bladder outflow obstruction
78
presenting symptoms of AKI
* suddenly feeing sick / vomiting
* peeing less than usual
* dehydration
* confusion
* drowsiness
79
examination findings in AKI
* hypertension
* distended bladder (palpable)
* Capillary refill- reduced (dehydrated)
* raised JVP, oedema (fluid overload)
80
investigation findings in AKI
1. urinalysis/ urine dipstick - proteinuria/ haemturia/ glucose (sign of renal disease)
2. Bloods:
* FBC- low platelets,(haemolysis),
* LFT
* U&Es- HIGH SERUM CREATININE
* Immunology
* immunoglobulins (Multiple myeloma)
* ANA (SLE)
* complement (low in lupus)
3. renal ultrasound (\<24hrs) - small kidneys = Chronic kidney disease
X-ray =\> renal stones
81
Management for AKI
1. IMMEDIATE =\> ABCDE approach + check for hyperkalemia
2. monitor volume status =\> control to euvolemia
3. stop Nephrotoxic drugs (NSAIDS/ ACE inhibitors/ aminoglycosides)
treat CAUSE
1. pre-renal =\> fluids to correct volume depletion. ABs for sepsis
2. post-renal =\> urinary catheter to drain bladder if theres blockage (check with CT)
3. UNRESPONSIVE to other treatment=\> renal replacement therapy (DIALYSIS)
Renal Replacement Therapy (RRT) considered if:
* Hyperkalaemia refractory to medical management
* Pulmonary oedema refractory to medical management
* Severe metabolic acidaemia
* Uraemic complications
82
prognosis of AKI
mortality depends on cause/ comorbidities/ early recognition (monitor with regular blood tests)
=\> also develop CKD
poor prognosis: age, multiple organ failure, oligouria, hypotension, CKD
83
complications of AKI
* hyperkalemia
* pulmonary oedema
* acidaemia
* bleeding
84
define chronic kidney disease
* progressive loss of kidney function present for \>3 months
* +/- kidney damage (GFR \<60ml/min)
Diagnostic criteria: (serum creatinine)
* A rise in serum creatinine of 26 micromol/L or greater within 48 hours
* 50% increase in baseline within 7 days
* A fall in urine output to less than 0.5 mL/kg/hour for more than 6 hours
85
classification of CKD
based on **_eGFR_**
* **Stage 1/normal : \>90** + CKD if evidence of kidney damange (microalbuminuria, proteinuria, haematuria, structural abnormalities, biopsy showing glomerulonephritis)
* Stage 2/ mild impairment: 60-89: pathology on biospy/imaging, or if transplan
* Stage 3/moderate: 30-59
* Stage 4/ severe: 15-29
* **Stage 5/ established renal failure: \<15**
86
risk factors for CKD
* **diabetes** (20%)
* **hypertension**/renovascular disease
* **AGE**
* glomerulonephritis (mainly IgA)
* systemic inflammation(SLE, vasculitis)
* Myelomas
* nephrotoxic drugs (ACE-i, gentamycin =\>ototoxic, NSAIDs, bisphosphonates, contrast)
Others:
* obesity
* CVD
* Pyelonephritis
* family Hx
* Smoking, neoplasias
* Chronic NSAID use
87
symptoms of CKD
* usually asymptomatic
Severe CKD (\<30 GFR):
* anorexia
* nausea + vomiting
* fatigue
* ptruitus
* peripheral oedema
* muscle cramps
* pulmonary oedema
88
examination findings of CKD
* usually non-specific signs
* can show underlying disease signs/ complications (anaemia)
Signs of CKD:
* skin pigmentation
* excoriation marks (scratch marks)
* pallor - anaemia
* uraemic tinge to skin (yellow-ish)
* purpura
* hypertension
* peripheral oedema/ pulmonary odema
* peripheral vascular disease
89
investigations for CKD
Bloods
* Hb
* **U&Es** - urea, creatinine, K+/Na+
* Ca2+ (low), phopshate (high)
* ESR
* glucose
Serology (identify cause/infection)
* antibodies- ANA (SLE), c-ANCA (granulomatosis with polyangiitis), anti-GBM (goodpasture's)
* hepatitis serology
* HIV serology
Urine
* urinalysis (**proteinuria/haematuria, albumin:creatinine ratio)**
* MC&S
* 24hr urine collection
* serum/urine electrophoresis (multiple myeloma)
Imaging
* **_USS_** - renal structural abnormlaities
* X-ray KUB - stones
Biopsy
* consider renal biopsy in progresive disease, nephrotic syndrome, systemic disease, AKI wihtout recovery
* biopsy unlikely to change treatment if GFR stable and P:CR\>150
90
management of CKD requires
1. lifestyle changes
2. reduce CVD risk - smoking, alcohol, salt
3. control bp - \<140/90 or \<130/80 (if diabetic)
4. avoid NSAIDs (ibuprofen), stay well hydrated when vomiting/diarrhoea
5. medication - statins - reduce CVD risk
6. Immunisations =\> flu/pneumococcal vaccines
appropriate referral to nephrology
* preparation for renal replacement therapy (dialysis/transplantation)
_Monitoring:_
* GFR and albuminuria annually
* high risk = 6 monthly
* very high risk = 3-4 monthly
* drop in eGFR \>25% is significant
91
What factors could can increase serum creatinine other than an AKI?
* if they already have CKD
* on trimethoprim (increase serum creatinine but doesn't affect glomerular filtration rate)
* recently completed pregnany (as serum creatinine lower during pregnancy)
92
consider referral to nephrology for CKD patients if
- stage G4/G5
- moderate proteinuria unless due to DM/already treated
- proteinuria with haematuria
- declining eGFR
- poorly controlled hypertension
- known/suspected rare/genetic cause of CKD
93
treatment to slow renal disease progression in CKD
1. BP: target \< 140/90 mmHg, 140/80 if DM or A:CR \> 70
2. RAAS: ACE inhibitor, ARB
- do not combine RAAS antagonists (risk of hyperkalaemia and hypotension)
3. glycaemic control
4. lifestyle
94
treatment of renal complications of CKD
1. anaemia - ESA, IV iron therapy
2. acidosis - sodium bicarb, caution if hypertensive/fluid overload
3. oedema - restrict fluids/sodium intake, loop diuretics, monitor fluid state/renal function
4. bone mineral disorders - dietary restriction,phosphate binders, vit D supplements, paricalcitol
5. restless legs/cramps - sleep hygiene, gabapentin/pregabalin/dopamine agonists
95
treatment of cardiovascular complications from CKD
* antiplatelets if at risk of atherosclerotic events
* atorvastatin for primary and secondary prevention of cardiovascular disease
* monitor GFR and potassium if on HF treatment
* low GFR may affected troponin and BNP
96
risk factors for decline of renal function in CKD
* increased BP
* DM
* metabolic disturbance
* volume depletion
* infection
* NSAIDs
* smoking
97
Complications of CKD
* **CVD** (due to hypertension, vascular stiffness, inflammation, oxidative stress, abnormal endothelial function)
98
define nephrotic syndrome and triad of features
* increased protein loss in urine usually due to damage to podocytes
Triad:
* proteinuria (\>3.5g/24hrs)
* hypoalbuminanaemia (\<25g/L)
* oedema (low albumin = lower serum oncotic pressure = fluid built up)
+ usually associated with hyperlipidemia
99
causes of nephrotic syndrome
children:
* **minimal change glomerulonephritis** (most common)
adults:
* **diabetes mellitus**
* **membranous glomerulonephritis**
* SLE
* Hepatits B/C
* Sickle cell
* Amyloidosis
* Malignancies
* HIV
* NSAIDs
* Alport syndrome (genetic conditon damages vessels in kidneys)
100
presenting symptoms of nephrotic syndrome
* FHx: atopy, renal disease
* PMHx: diabetes, SLE, viral infections
* swelling of face,abdomen, limbs, genetalia (hypoalbuminanaemia)
* symptoms of cause (SLE =\> joint pain, tiredness, skin rash)
* +/- vomiting
101
signs of nephrotic syndrome
* oedema- perioribital, peripheral, genital
* ascities- thrills, shifting dullness
* anaemia
* tachycardia
102
Investigations for nephrotic syndrome
Bloods:
* FBC
* U&Es
* LFTs (low albumin)
* ESR/CRP
* lipid profile (check for hyperlipidemia)
* glucose (check for diabetes)
* immunoglobulins
* complement
Urine
* urinalysis
* MC&S
* 24hour collection of urine
Identify cause
* ANA, anti-dsDNA antibodies (SLE)
* ASO tire (Group A- strep. infection)
* serology (HBV)
* anti-glomerular basement antibodies (goodpasture's syndrome)
* ANCA (polyangitis with granulomatosis)
Imaging:
* Renal USS (exclude reflux nephropathy)
Renal biopsy
103
management of nephrotic syndrome
1. Treat cause:
* soidum + fluid restrict
* oral/IV diuretics (loop)
* ACE inhibitors (reduces Na+ reabsorption)
104
Complications of nephrotic syndrome
* **Infection** (most common)- sepsis, pneumonia, peritonitis
* Clots
* hyperlipidemia =\> increased CVD
* AKI/CKD
105
define prostate cancer
* malignancy of prostate gland (usually adenocarcinomas)
106
causes/ risk factors of prostate cancer (ROAD AF)
* Raised testosterone
* Occupation (exposure to cadmium)
* Afro-carribeans
* Diet
* Age
* Fmily Hx
107
symptoms of prostate cancer
* usually asymptomatic
* Lower urinary tract obstruction - frequency, hesitancy, terminal dribbling, nocturia
* visible haematuria + erectile dysfuntion
* Metastatic spread
1. systemic spread; FLAWS (malaise, weight loss, anorexia)
2. bone pain
3. spine compression
4. paraneoplastic syndrome (hypercalcemia)
108
signs of prostate cancer
DRE
* hard nodular prostate
* loss of midline sulcus
109
investigations for prostate cancer
1. Prostate specific antigen (first line but not specific)
2. DRE
3. Transrectal US guided biopsy (GOLD STANDARD)
4. Isotope bone scan to check for metastasis
110
Management for prostate cancer
T1/T2
* conservative - active monitoring or watchful waiting
* SURGERY: radical prostatectomy
* radiotherapy
T3/T4 (locally advanced)
* hormone therapy
* radical prostatectomy
* radiotherapy
Metastatic disease: (reduce androgen levels)
* GnRH agonists (initial rise in LH =\> lower LH long term / antagonists
* bicalutamide (non-steroidal blocks androgen receptor)
* cyproterone acetate (steroidal anti-androgen)
* abiraterone
* bilateral orchidectimy
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define erectile dysfunction
inability to get or maintain an erection
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causes of erectile dysfunction
* vascular- CVD risk factors,
* neurogenic- MS, parkinson's
* prostate cancer
* peyroniere's disease - inflammation of penis =\> bending
* hormonal- hypogonadism, hypo/perthyroidism, cushing's
* drugs- antihypertensives, antidepressants, antipsychotics
* psychological - depression/anxiety
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Risk factors for erectile dysfunction (CVD)
* diabetes
* smoking
* poor diet- dyslipidemia
* low exercise
* obesity
* hypertension
* metabollic syndrome
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Symptoms for organic/pscyhogenic erectile dysfunction
organic cause
* gradual onset of symptoms
* normal tumuscence (erection?)
* normal libido
* risk factors (drugs, high acohol + smoker)
psychogenic cause
* sudden onset of symptoms
* decreased libido
* good quality masturbation
* recent life/relationship problems
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Examinations for erectile dysfunction
Basic obs:
* bp, HR, waist circumference, weight, BMI
Examine genetalia (for sudden onset)
* malignant lesions
* prostate enlargement/nodularity
* hypogonadism (small testes, changes in secondary sexual characteristics)
* penile deformity (Peyronie's disease- penis inflammation =\> bending)
Check for gynacomastia
DRE (Hx of prostate cancer/ \>50/ obstructive urinary symptoms)
* enlarged prostate
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Investigations for erectile dysfunction
Bloods:
* HbA1c
* lipid profile
* total testosterone
* FSH, LH, prolactin
* PSA (if abnormal DRE/ \>50+ risk factors for prostate cancer)
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Management for erectile dysfunction
Conservative
* manage modifiable risk factors (smoking, alcohol, weight, increase exercise, manage CVD/diabetes/hypertension)
Medical- PDE-5 inhibitors (phosphodiesterase-5)
* viagra (sildenafil)
* cialis (tadalafil)
* vardenafil (Levitra)
* avanafil (Spedra)
Referral:
* urology- young men with persistant dysfunction, urinary symptoms
* endo- hypogonadism features (abnormal FSH,LH,prolactin or testsoterone)
* cardio- have CVD
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How to Cardio-risk stratification patients with erectile dysfunction
Low risk
* asymtomatic, \<3 risk factors for CAD
* controlled hypertension
* can do exercise at moderate intesitiy without symptoms
Intermediate risk
* \>3 risk factors for CAD
* mild angina
* past MI
* LVD/CHF
* atherosclerotic disease
High risk
* unstable angina
* uncontrolled hypertension
* LVD/CHF
* recent MI without intervention
* HOCM
* moderate/severe valve disease
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define urinary incontinence
= leakage of urine
most common in elderly females
Types
* stress- increased abdominal pressure (MOST COMMON)
* urge- increased urgency
* overflow- bladder doesn't empty fully due to obstruction
* functional- physical/mental impairment can't get to toilet in time
* mixed (stress + urge)
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causes of urinary incontinence
stress
* **pregnancy/childbirth**
* exercise
* cough/sneezing
* **elderly**
* **obesity**
* hysterectomy - damage bladder/nerves
urgency
* infection
* cystitis
* neurological disease - MS, parkinson's, stroke, spinal injury (CES)
* alcohol/caffeine
overflow:
* BPH/ prostate cancer
* obstruction (stones)
functional
* physical: arthritis- can't unbutton
* mental: Parkinson's/ dementia
OTHER:
* medication (ACE-inhibitors, duretics, antidepressants, sedatives, HRT)
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investigations for urinary incontinence
* urinalysis (check for infection)
* blood glucose (check for diabetes)
* bladder diary
* post-voidal residual volume
Before surgery:
* cytoscopy
* pelvic MRI
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management for urinary incontinence
Conservative
* lifestyle modification - reduce caffeine, control fluids, lose weight
* kegal exercises - strengthen pelvic floor muscles
* bladder training
* pads/ catheters
Medication
* STRESS (if unsuitable for surgery) =\> antidepressants -increase urethra tone
* URGE =\> antimuscurinics (oxybutynin)/ anticholinergics -
**_Surgery_**
Stress: increase urethra tone
* colposuspension - stitch neck of bladder higher up
* sling surgery - sling around bladder neck to stop leakage
* bulking agents - increase urethra tone
* artifical sphincter insertion
Urge: calm overactive bladder
* Botox - relax detrusor muscle
* Sacral nerve/posterior tibial nerve stimulator - less signals to urinate
* IF BPH =\> tamulosin (alpha-blocker -shrinks prostate)
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complications of urinary incontinence
* contact dermatitis
* sores/ulcers =\> SECONDARY INFECTION
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