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Renal GU FCM Flashcards

1
Q

what is the most common form of bladder cancer

A

transitional cell carcinoma

others include squamous cell and adenocarcinoma

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2
Q

How does bladder cancer present?

A 
haematuria 
dysuria 
urinary frequency
lower back, pelvic or lower abdominal pain 
weight loss/fatigue
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3
Q

How can bladder cancer be investigated?

A

Cytoscopy - look inside bladder (+take a biospy).

urinanalysis and CT scans can also be useful

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4
Q

What does management of bladder cancer involve?

A

dependent on stage of bladder cancer

low grade - surgical removal may be favoured if it hasn’t metastasised.

IV or systemic chemotherapy

other options include radiotherapy, immunotherapy or targeted therapy

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5
Q

what are most prostate cancers?

A

adenocarcinomas

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6
Q

How can prostate cancer/carcinoma present?

A

unexplained. ..
- lower back pain
- lethargy
- erectile dysfunction
- hematuria

Weight loss and also lower urinary tract symptoms - hesitancy, frequency, urgency, terminal dribbling and/or overactive bladder.

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7
Q

What examinations/investigations are done when prostate cancer is suspected?

A

DRE (physical rectal exam)
PSA testing
Transrectal US + biopsy
(additional MRI imaging)

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8
Q

How is prostate cancer managed?

A

dependent on the prognostic risk accounting for the clinical staging, PSA test and Gleason score.

TNM Stage
1 = watchful waiting/active surveillance
2 = radical treatment - radical prostectomy, external beam radiotherapy and brachytherapy
3 = adjunctive & palliative treatment - chemo & hormonal therapy

things to consider = pt age & preference, co-morbidities,

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9
Q

Where does renal cell carcinomas originate?

A

in the lining of the proximal convoluted tubule

commonest type of kidney cancer in adults

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10
Q

What does renal cell carcinoma present with?

A 
hematuria 
persistent back or flank pain 
loss of appetite/unexplained weight loss
tiredness & possibly fevers 
excessive hair growth in women 
lump in the abdomen and flank.
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11
Q

How is renal cell carcinoma investigated?

A

CT scan
abdominal or kidney US + biopsy
Urine examination
FBC, LDH, LFTs

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12
Q

How is renal cell carcinoma managed?

A

Dependent on the stage

Earlier stages may indicate surgical intervention - removing tumour via partial/full nephrectomy alongside some adjunctive therapy

cryoablation and radio-frequency ablation

Targeted therapy/immunotherapy or radiation therapy

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13
Q

What is key about Wilm’s tumour?

A

a kidney cancer which primarily affects children

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14
Q

How does Wilm’s tumour present?

A 
constipation 
abdo pain/discomfort or abdo swelling 
nausea & vomiting 
weakness, fatigue and loss of appetite 
fever and SOB 
hematuria, HTN 
palpable abdominal mass
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15
Q

How is wilm’s tumour investigated?

A

Abdo X-ray/ US + biopsy

blood and urine tests

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16
Q

How is Wilm’s managed?

A

in non-metastatic cases the main treatments include

  • surgery (nephrectomy)
  • chemotherapy
  • radiation therapy
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17
Q

What are the 2 types of testicular cancer?

A 
Seminoma = older age/gradual onset 
Non-seminoma = younger age/ more agressive/acute onset
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18
Q

How will testicular cancer present?

A

testicular pain or discomfort /dull ache
testicular swelling
lower abdo/back pain
enlargement of breast tissue - gynaecomastia
lump/enlargement within either testes
heaviness in scrotum
sudden collection of fluid in scrotum

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19
Q

How is testicular cancer investigated?

A

male genitalia examination
US to examine internal structure of testes
Blood tests - B-chorionic gonadotropin and a-fetoprotein (usually elevated)

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20
Q

What does management of testicular cancer involve?

A

surgery to remove the testicles and sometimes the nearby lymph nodes

radiation therapy/chemotherapy used either prior ot in adjunct to surgery

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21
Q

How does benign prostatic hyperplasia (BPH) present?

A 
urinary urgency or frequency 
nocturia
difficulty initiating urination
weak stream - intermittence 
terminal dribbling 
inability to completely empty bladder 
associated with UTIs or hematuria
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22
Q

how is BPH examined and investigated?

A

PR Exam - check prostate enlargement

Urine test - rule out infections
Blood tests - U&E to check renal function
PSA blood test - usually raised in BPH

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23
Q

How is BPH managed?

A 
usually started on alpha-blockers which makes urinating easier 
5-alpha reductase inhibitors prevent hormone changes 
or Tadalafil  (PDE5 inhibitor)

minimally invasive/surgical therapy or laser therapies

  • prostatic urethral lift
  • embolisation
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24
Q

How does acute Glomerulonephritis present?

A 
puffiness in face 
urinating less often 
hematuria/dark coloured urine
fluid in lungs - presents as a cough 
high BP
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25
Q

How does chronic Glomerulonephritis present?

A 
swelling in face and ankles
frequent nocturia 
abdominal pain 
frequent epistaxis 
bubbly/foamy urine
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26
Q

How do we investigate glomerulonephritis?

A
  • urine tests
  • blood -creatinine and Blood urea nitrogen (BUN)
  • imaging tests
  • biopsy - determine cause & confirm diagnosis
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27
Q

How do we manage glomerulonephritis?

A

dependent on the extent of GN and the underlying cause
antibiotics in infective cases
Control HTN using ACEi or ARBs
chronic GN may involve dietary changes and taking diuretics to reduce oedema
corticosteroid given to suppress and autoimmune attacks

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28
Q

What can cause glomerulonephritis?

A

Infections
Immune diseases
Scarring due to HTN, DM or focal segmental glomerulosclerosis
Vasculitis

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29
Q

What are the 2 main characteristic of an AKI (/acute renal failure)?

A

Abnormal increase in creatinine

Drop in urine output

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30
Q

What are the causes of AKI divided into? what do each involve?

A

Pre-renal - reduced perfusion to the kidneys causing GFR to drop. examples include Hypovolemia, lower CO and antihypertensives

Renal - toxins & drugs, vascular conditions, abnormalities in glomerulus, tubular problems or interstitial problems

Post-renal - mainly due to obstruction. examples include stones, blocked catheter or enlarged prostate.

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31
Q

How does AKI present?

A
  • decreased urine output
  • fluid retention = swelling of legs, ankles and feet
  • SOB, chest pain/pressure
  • nausea or coma in severe cases
  • creatinine rise of 26mmol/L within 48hrs
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32
Q

How do we investigate an AKI?

A

measure urine output - monitor over 24hrs
urine tests/ urinalysis
Blood tests - rapidly rising levels of urea & creatinine
imaging - US or CT to look for any structural abnormalities
Biopsy - guides/confirms diagnosis as well as aiding staging of AKI

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33
Q

How is AKI managed?

A

based upon cause - start by managing any of the underlying causes

offer supportive tx on maintaining hydration
consider stopping any nephrotoxic medication
close monitoring of creatinine

diuretics to reduce swelling,

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34
Q

what is classified as chronic renal failure/kidney disease?

A

reduction in renal function, structural damage or both presenting fro 3 months with associated health implications

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35
Q

what are some causes of CKD?

A 
Type 1 &2 diabetes
HTN 
Glomerulonephritis 
Polycystic kidney disease 
Prolonged obstruction 
vesicoureteral reflux 
recurrent UTI
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36
Q

How does CKD present?

A 
nausea & vomiting 
loss of appetite
fatigue & weakness 
persistent itching 
sleep problems/insomnia
swelling in feet/ankles 
changes to urine output 
decreased mental 'sharpness'
SOB, chest pain 
muscle twitching
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37
Q

How is CKD investigated?

A

Blood test - U&Es
urine tests
Imaging tests
Biospy

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38
Q

How is CKD managed?

A

identify and treat underlying cause
monitoring of renal function - creatinine, eGFR, ACR
dialysis
renal replacement therapy - definitive

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39
Q

What characterises nephritic syndrome?

what causes it?

A

nephritic syndrome is characterised by hematuria
also has mild proteinuria and very high BP (malignant HTN)

cause = endothelial wall damage mediated by immune-complex formation (IgA nephropathy)
post infection, lupus, infective endocarditis

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40
Q

what characterises nephrotic syndrome?

what causes it?

A

involves heavy proteinuria (>3.5g/day)
hypoalbuminaemia and fluid overload

causes = structural damage to slit diaphragm, foot processes and depleting in podocyte numbers

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41
Q

How does nephritic syndrome present?

A 
Haemturia 
oedema 
reduced urine output 
uraemic symptoms - fatigue and tiredness 
HTN, Oliguria
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42
Q

how does Nephrotic syndrome present?

A 
oedema 
frothy urine 
fatigue 
poor appetite 
recurrent infections 
SOB
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43
Q

How is nephritic syndrome investigated?

A

urine dipstick - leukocytes,protein and blood
urine ACR
acute renal screen

Acute renal screen = tests measure the amounts of various substances, including several minerals, electrolytes, proteins, and glucose (sugar), in the blood to determine the current status of the kidneys

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44
Q

How is nephrotic syndrome investigated?

A

urine ACR

Acute renal screen

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45
Q

How is nephritic syndrome managed?

A

urgent renal referral
BP control +/- diuresis
treat underlying cause once confirmed on biopsy

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46
Q

How is nephrotic syndrome managed?

A 
dependent on the underlying cause 
often 
- BP management 
- diuresis 
- prophylaxis against VTE

aim to reduce proteinuria

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47
Q

What is balanitis?

A

inflammation of the glans penis which can result from infection, trauma or be premalignant as well as from some form of dermatitis/psoriasis

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48
Q

how does balanitis present?

A

penile soreness/itch
dysuria and dyspareunia
redness and swelling of glans penis
inability to retract/ lightening foreskin
meatal stensis - suggests lichens sclerosis
bleeding from foreskin/ odour

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49
Q

How is balanitis investigated?

A

male genitalia exam
consider STI screen
HbA1c to assess diabetes or underlying HIV
can perform sub-preputial swab

50
Q

How is balanitis managed?

A

dependent on cause

  • if dermatitis = give topical hydrocortisone
  • if candidal = imidazole cream
  • if bacterial = oral flucloxacilin - clarithromycin if contraindicated
  • anaerobic causes = metronidazole
51
Q

How does prostatitis present?

A 
UTI like symptoms = dysuria, frequency & urgency 
lower back pain 
pain on ejaculation 
fever 
tachycardia 
perineal, penile or rectal pain
52
Q

How is prostatitis investigated?

A

abdo/genitalia and rectal examination
MSU sample for dipstick to check for infection
Bloods - FBC (PSA)
Consider STI screen

53
Q

How is prostatitis managed?

A

oral ciprofloxacin for 14days or Levofloxacin
advise analgesia for pain and fevers
advise adequate hydration
follow up after 48hrs and review in 14 days

emergency admission if…

  • unable to take oral Abx
  • severe symptoms or septic signs
  • Diabetic or have a serious urological condition
54
Q

What does epididymitis present with?

A 
swollen, red or warm scrotum 
testicular pain and tenderness 
dysuria, urgency and frequency 
penile discharge 
lower abdo/pelvic pain 
blood in semen
55
Q

How would epididymitis be investigated?

A

abdo and genitalia examinations
Bloods - FBC, CRP, ESR
consider STI screen
US to rule out testicular torsion

56
Q

How is epididymitis managed?

A

unknown organism = ceftriaxone 1g IM plus oral doxycycline BD 10-14days OR oral orfloxacin BD 14/7

Chlamydia organism = oral Doxycyline BD for 10-14/7
or oral orfloxacin BD 14days

Enteric organism (E.Coli) = Orfloxacin BD 14/7 OR levofloxacin PO BD 10 days

advise - bedrest, scrotal elevation, cold packs, analgesia, supportive underwear

57
Q

What does urethritis present like in men?

A

mucopurulent & purulent urethral discharge
itching/burning sensation near the opening of the penis
presence of blood in semen
penile irritation/ discomfort

58
Q

What does urethritis present like in women?

A

frequent discomfort and burning sensation

abnormal discharge

59
Q

What investigations should be done for suspected urethritis?

A

genitalia/abdominal examinations
urine samples or swabs may be taken
blood tests for infection/screen for UTI

60
Q

How is urethritis managed?

A

usually antibiotics including doxycycline, azithromycin or orfloxacin
analgesia
STI notification and contact tracing - sexual abstinence

61
Q

What does pylonephritis ?

A

main triad:
unilateral flank/loin pain
nausea and vomiting
fever

other presentations

  • new myalgia/flu-like symptoms
  • tenderness in ribs/flanks
62
Q

How can we investigate pylonephritis?

A

MSU/CSU - determine infecting organism
dipstick - nitrites and leukocytes
abdo examination

63
Q

How is pylonephritis managed?

A

offer antibiotics - cefalexin first line
others include co-amoxiclav, trimethoprim or ciprofloxacin (based on sensitivities)
analgesia
avoid dehydration & advise keeping hydrated
reassess in 48hrs for effectiveness of antibiotics

septic signs - hospital admission

64
Q

How does urinary incontinence present?

A 
occasional, minor leaks of urine 
usually when doing some form of activity 
sudden urge to urinate 
strain to pass, intermittent stream 
feeling incomplete passing of urine
65
Q

How is urinary incontinence investigated?

A

perform a general examination - check weight, gait, neurological disease
pelvic examination - check for any prolapse and check pelvic muscle tone bimanually
urinalysis - check for any infection
post-voidal residue - catheter or US used to check how much urine retained in bladder after voiding

66
Q

How is urinary incontinence managed?

A
  1. lifestyle advice - reducing caffeine, fluid intake, weight loss and smoking cessation
  2. behavioural techniques - bladder training (delaying urge) and scheduling toilet trips
  3. offer referral for 3 months of supervise pelvic floor muscle training
  4. consider Absorbent containment products, hand-held urinals, and toileting aids
  5. conservative Tx fails = refer to special urologist, urogynaecologist
  6. offer duloxetine as 2nd line (anti-depressant)

for UUI - offer oxybutynin, tolterodine/darifenacin as 1st line OR mirabegron if other contraindicated

67
Q

What does cryptorchidism presented with?

A

testicular asymmetry

scrotal hyperplasia or asymmetry

68
Q

How is cryptorchidism investigated/examined?

A

usually diagnosed with clinical examination

sometimes US used if clinician is unsure

69
Q

How is cryptorchidism managed?

A

suspected undescended testes in dependent on the location & presence of testes
specialist management - includes surgical Tx/hormonal Tx

70
Q

What does the varicocele present?

A

painless swelling - usually on left side
feels like a ‘bag of worms’
sometimes scrotal groin pain
ages in 12yrs +
Disappears on lying and reappears on standing.

71
Q

What does the hydrocele present?

A

fluctuant, ovoid swelling enveloping the testis
may experience some discomfort/heaviness

common in neonates

72
Q

How are varicoceles investigated/examined?

A

usually clinical diagnosis
US with colour flow
Doppler semen analysis

73
Q

How are hydroceles investigated?

A

blood urine tests
US
transillumination

74
Q

How is varicocele managed?

A

Subclinical or grade I varicocele - no Tx necessary

Grade II/III and asymmetrical testes - Observe with annual examinations

offer semen analysis if fertility is a concern

Grade II/III or symptomatic varicocele and abnormal semen parameters - refer to urologist for possible surgery

75
Q

How does Urothialiasis present?

A 
pain in lower abdomen or groin 
pain in testicles for males 
high temperature 
severe pain that comes and goes and sweating 
nausea and vomiting 
haematuria
76
Q

How is urolithiasis investigated?

A

blood tests - calcium/uric acid
urine testing
imaging CT, abdo, x-rays US
analysis of passed stones

77
Q

What does management of urolithiasis involve?

A

Conservative - watchful waiting to see if there is spontaneous passing of stones

medical management - alpha-blockers (tamsulosin) & NSAIDs for pain

Surgical management - shockwave lithotripsy - to break stone down into fragments making it easier to pass

78
Q

What does paraphimosis involve?

A

A condition affecting males who are uncircumcised - foreskin which can no longer be pulled forward - becomes stuck and swollen

79
Q

How does paraphimosis present?

A

inability to return the foreskin back to its normal position
foreskin has become swollen and painful
tip of penis may become discoloured = (dark red/blue) due to lack of blood flow

80
Q

How is the paraphimosis managed?

A

treatment varies depending on age or severity

  1. treat/reduce the swelling by applying ice packs, bandaging tightly around the area
  2. needles to drain any pus/blood
  3. inject hyaluronidase
  4. analgesia for pain - may give anaesthetic/nerve block or oral narcotic

severe cases require complete circumcision

81
Q

What is testicular torsion?

A

The twisting of the spermatic cord which is responsible for blood supply to the scrotum

82
Q

How does testicular torsion present?

A 
Sudden, severe scrotal pain 
swelling of the scrotum 
abdo pain 
nausea & vomiting 
testicle positioned higher than normal/unusual angle 
frequent urination 
fever
83
Q

what are the investigations for testicular torsion?

A

urine test

scrotal US

84
Q

How is testicular torsion managed?

A

if suspected admit immediately to urology or paediatric surgery

distortion is required within 4-8hours to avoid any ischemic damage

85
Q

What is urinary retention and what causes it?

A

a condition where you cannot empty your bladder and so urine is retained

many causes usually categorised as obstructive/non-obstructive

  • prostate cancer/BPH
  • urethral stricture
  • severe constipation
  • pelvic tumour
  • perineal pain
  • drugs - antimuscarinics, opioid analgesics and anaesthetics
86
Q

How is urinary retention investigated?

A

measure serum creatinine and eGFR
PSA testing if indicated
Abdominal examination may show abnormal palpation/percussion

87
Q

How is acute urinary retention managed?

A

insert urethral catheter and discuss how the UR should be treated/managed
- alpha-blcokers - 65yrs+ which is started 24hrs prior to catheter removal and used until several hours of normal voiding is established

  • intermittent urethral catheterization
  • Long term indwelling catheter
88
Q

How is chronic urinary retention managed?

A
  1. exclude any non-obstructive causes of reduced urine flow
  2. check serum creatinine
  3. refer for specialist assessment - arrange imaging

management options

  • no catheterization - regular monitoring of renal function, volume of retention & imaging
  • intermittent catheterization
  • permanent indwelling catheter
  • surgery to divert urine externally
89
Q

What is the most common form of Glomerulonephritis?

A

membranous glomerulonephritis - autoantibody damage to the GBM - increasing permeability and allowing leakage of protein

90
Q

How does membranous Glomerulonephritis present?

A

Nephrotic syndrome - proteinuria, Hypoalbuminemia, oedema

91
Q

Investigations for Membranous Glomerulonephritis

A

Electron microscopy - thickened GBM, ‘spike & dome’ appearance, effacement of foot processes

Immunofluorescence - granular appearance

92
Q

Mx of membranous Glomerulonephritis?

A

treat underlying cause
All pts = ACEi/ARB
immunosuppression = steroids and cyclophosphamides

93
Q

How does membranoproliferative glomerulonephritis?

A

Usually present as nephrotic - proteinuria, hypoalbuminemia and oedema

94
Q

Ix of membranoproliferative glomerulonephritis?

A

light microscopy - tram-track appearance

immunofluorescence - granular appearance

electron microscopy of renal biopsy = ‘dense deposits’

95
Q

mx of membranoproliferative glomerulonephritis?

A

steroids are usually effective

96
Q

What is rapidly progressive glomerulonephritis?

A

GBM breaks down as a result of proliferation and deposition of crescent shaped cells

97
Q

how does rapidly progressive glomerulonephritis present?

A

nephritic syndrome

  • haematuria
  • oliguria
  • azotemia
  • HTN
  • rapid loss renal function/GFR
98
Q

Ix of Rapidly progressive glomerulonephritis?

A

light microscopy - crescent shaped cells in the glomeruli

immunofluorescence
type 1 - linear
type 2 - granular
type 3 - negative

99
Q

mx of rapidly progressive glomerulonephritis?

A

immunosupressants - prednisolone & cyclophosphamide

plasmapheresis in some cases - goodpasture’s

100
Q

What is post-streptococcal glomerulonephritis?

A

inflammation resulting from a streptococcal infection - Group B haemolytic strep

typically in children - ~6weeks after skin infection/impetigo
1-2 weeks after pharyngitis

101
Q

How does post-streptococcal glomerulonephritis present?

A

nephritic syndrome

  • visible haematuria
  • oliguria
  • peripheral & periorbital oedema
  • malaise and headaches
  • HTN
102
Q

Ix for post-streptococcal glomerulonephritis?

A

light microscopy - glomeruli appear enlarged and hypercellular

electron microscopy - deposits in the subepithelium appear as humps

Immunofluorescence - granular or ‘starry sky’ appearance

bloods - Anti-DNAse B, raised ASO titre and decreased complement levels

103
Q

Mx for post-streptococcal glomerulonephritis?

A

usually supportive mx

104
Q

complications of post-streptococcal glomerulonephritis

A

some children can go onto developing renal failure

1/4 of adults have rapidly progressive GN

105
Q

What is focal segmental glomerulosclerosis?

A

FSGS typically develops in young adults causing nephrotic syndrome and kidney disease

106
Q

How does FSGS present?

A

foamy urine - loss of albumin via urine
hypoalbuminaemia
oedema
decline in kidney function

hyperlipidemia and lipiduria
drop in RBC - anaemia

107
Q

How is FSGS Investigated/diagnosed?

A

urinalysis - increased protein/lipid

blood test - drop in RBC, lipids and protein

kidney biopsy - scarring and ‘glassy appearance’

light microscopy - segmental sclerosis and hyalinosis

108
Q

Mx of FSGS?

A

dietary salt restrictions and diuretics (tx oedema)
steroids +/- immunosupressants

antihypertensives & statins & lifestyle changes
if secondary - tx of underlying cause

109
Q

When Is renal replacement therapy considered?

A

CKD developing renal failure with GFR <15ml/min

110
Q

What types of RRT are there and what do they involve?

A
  1. HAEMODIALYSIS - most common, 3x week, 3-5hr sessions, arteriovenous fistula surgery required 8 weeks prior to starting
  2. PERITONEAL DIALYSIS - dialysis solution (high dose dextrose) injected through permanent catheter
  3. RENAL TRANSPLANTATION - average wait 3yrs, renal vessels connected to external iliac vessels, lifelong immunosuppression to prevent rejection
111
Q

What is IgA nephropathy?

Presentation?

A

commonest cause og Glomerulonephritis, presenting usually in childhood during a URTI/GI infection

young males, macroscopic haematuria,
hx of resp tract infection

rarer - proteinuria in nephrotic range, renal failure

  • Henloch-schnolein purpura presents similarly but will manifest in the skin, connective tissue, joints and GI tract
112
Q

Ix of IgA Nephropathy?

A

Light microscopy - mesangial proliferation
Electron microscopy - immune deposits of mesangium
Immunofluorescence - presence of immune complexes

113
Q

Management of IgA nephropathy?

A

isolated haemturia/minimal proteinuria & normal GFR = no tx needed, Follow up and check renal function

Persistent haematuria & slight drop in GFR = ACEi

Active disease - declining GFR & unresponsive to ACEi = immunosupression with costicosteroids

114
Q

What is Minimal change disease?

Presentation?

A

most common cause of nephrotic syndrome in children

Presentation

  • nephrotic syndrome - proteinuria
  • normal renal function
  • normal level of complement
  • normotensive
115
Q

Ix and finidngs for Minimal change disease?

A

Light micrscopy - normal glomeruli, ‘minimal change’

Electron microscopy - fused podocytes and effacement of foot processes

Immunofluorescence = negative, change isn’t due to immune complexes

116
Q

Mx of minimal change disease?

A

usually steroids responsive

if steroids resistant - cyclophosphamide

117
Q

What is polycystic Kidney disease?

A

A commonly inherited kidney disease - cysts on kidneys

118
Q

presentation of PKD?

A 
most commonly presents with loin pain 
HTN 
bilateral kidney enlargement 
gross haematuria following trauma 
UTI/Pyelonephritis 
intracranial (berry) aneurysms
119
Q

How is PKD investiagted?

Diagnosis?

A

Bloods - FBC, U&E, creatinine and eGFR, bone profile

Urinanalysis and urine MC&S

Imaging - US/CT

aged <30 - uni/bilateral 2 cysts
aged 30-59 - 2 cysts bilaterally
>60 - 4 cysts bilaterally

120
Q

Management of PKD?

A

tolvaptan - slows progression of cyst development
monitoring RFs/exacerbations
supportive management

FCM (8 decks)

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