Renal + Urogenital Flashcards
(159 cards)
1
Q
What is the function of the urinary tract?
A
- to collect continuously produced urine
- to store it under safe conditions
- to expel urine when socially acceptable
2
Q
What are the key features in the filling of a normally functioning bladder?
A
- continence
- sensation of bladder volume
- receptive relaxation: relaxes to allow larger volume without increased pressure
3
Q
What are the key features in the voiding of a normally functioning bladder?
A
- voluntary initiation
- complete emptying
4
Q
What incontinence problems can occur in neuropathic bladder management?
A
- incontinence: neurogenic detrusor overactivity ( sphincter contracts by itself
- stress incontinence: when pressure inc in abdomen e.g. coughing, urine leaks out - normally prevented by guarding reflex
5
Q
What upper tract injury problems can occur in neuropathic bladder management?
A
- infection
6
Q
What are the 5 main functions of the kidney?
A
- fluid balance and BP control
- waste, toxin and drug removal
- red cell production (generates erythropoietin)
- vit D metabolism
- acid-base regulation
7
Q
Why are most people with advanced CKD anaemic?
A
- not enough EPO to stimulate bone marrow to produce RBC
- leads to normocytic anaemia
8
Q
What is acute kidney injury?
A
- acute drop in kidney function over hours or days
- diagnosed by measuring serum creatinine
9
Q
What are the NICE criteria for AKI?
A
- rise in creatinine of ≥25µmol/L in 48h
- rise in creatinine of ≥50% in 7 days
- urine output of < 0.5ml/kg/hr for > 6hrs
10
Q
What are risk factors for AKI?
A
- CKD
- heart failure
- diabetes
- liver disease
- older age
11
Q
What are pre-renal causes of renal failure?
A
- due to inadequate blood supply to the kidneys, reducing filtration of blood
- hypovolaemia
- reduced CO
- drugs that reduce BP
12
Q
What are causes of renal failure?
A
- intrinsic disease leads to reduced filtration of blood
- Glomerulonephritis
- Interstitial nephritis
- Acute tubular necrosis
- rhabdomyolysis: CK in skeletal muscle is nephrotoxic
- nephrotoxic drugs and antibiotics
13
Q
What are post-renal causes of AKI?
A
- caused by obstruction to the outflow of urine causing back pressure and reduced kidney function
- renal stones
- cancer
- enlarged prostate
- blocked catheter
14
Q
What are symptoms of AKI?
A
- nausea
- dehydration and less urination
- diarrhoea
- confusion and drowsiness
15
Q
How is AKI investigated?
A
- urinalysis
- leucocytes and nitrites: infection
- protein and blood: acute nephritis
- glucose: diabetes
- ultrasound for obstruction
16
Q
How is AKI managed?
A
- fluid rehydration if pre-renal
- stop nephrotoxic medication
- relieve obstruction if post renal
- dialysis if serious
17
Q
How is CKD investigated?
A
- eGFR calculated using U&E
- proteinuria using albumin:creatinine ratio (≥3mg/mmol)
18
Q
Which LUTS fall into storage?
A
- frequency
- urgency
- nocturia
- incontinence
19
Q
Which LUTS fall into voiding?
A
- poor flow
- intermittency
- straining
- terminal dribbling
- hesitancy
20
Q
Which LUTS fall into post micturition?
A
- sensation of incomplete voiding
- post-micturition dribbling
21
Q
What can cause difficulty voiding?
A
- benign prostatic hyperplasia
- urethral stricture
- masses
- prolapse
- non-obstructive: atonic bladder: insufficient detrusor contraction
22
Q
What is stress incontinence?
A
- weakness of the pelvic floor and sphincter muscles
- leads to urine leakage when there is inc pressure on the bladder
- occurs when laughing, coughing, sneezing
23
Q
What is urge incontinence?
A
- overactivity of detrusor leads to sudden urge to pass urine
24
Q
What is overflow incontinence?
A
- occurs in chronic urinary retention
- due to obstruction of outflow of urine
25
What are the risk factors for renal cell carcinoma?
- smoking
- obesity
- genetic
- more common in males
- hypertension
- dialysis
26
How does renal cell carcinoma present?
- triad: haematuria, loin pain, palpable mass
- mostly found incidentally on scan
27
How is renal cancer staged?
- Stage 1: tumour diameter < 7cm
- Stage 2: diameter > 7cm
- Stage 3: local size, spread to nearby tissues and veins
- Stage 4: metastasis occurred
28
How is renal cancer investigated?
- CT TAP used for staging
- MRI if needed
- biopsy
29
How is renal cancer managed?
- active surveillance if slow growing and treatment would be detrimental
- radiofrequency ablation, cryotherapy, arterial embolisation
- partial or radical nephrectomy
30
What are the types of renal cell carcinoma?
- clear cell carcinoma
- papillary carcinoma
- chromophobe
- collecting duct
31
What paraneoplastic features are associated with renal cell carcinoma?
- polycythaemia: unregulated EPO
- hypercalcaemia: PTH mimic
- hypertension: inc renin secretion and physical compression
- Staffer's syndrome: abnormal LFTs without liver metastasis
32
What are common complications of renal cell carcinoma?
- spread to renal vein, IVC
- cannonball metastases appear as defined circular opacities scattered through lung fields on CXR
33
What are the risk factors for bladder cancer?
- smoking
- exposure to aromatic hydrocarbons, dyes, rubber,
- industrial exposures: hairdressers, leather and chemical workers
- drugs e.g. cyclophosphamide
34
How does bladder cancer present?
- painless, visible haematuria
- LUTS without cause
- recurrent UTIs
35
Where does bladder cancer occur and what are the types?
- transitional cell carcinoma = 90%: affects urothelium
- squamous cell carcinoma: dysplasia from irritation e.g. stones, schistosomiasis
36
How is bladder cancer investigated?
- flexible cystoscopy: direct visualisation which is very quick
- ultrasound
37
What are the surgical management options for bladder cancer?
- transurethral resection (TURBT) is used for non muscle invasive bladder cancer
- tumour removal during cystoscopy
- radical cystectomy: removal of entire bladder
38
How is bladder cancer staged?
- non-muscle invasive bladder cancer vs muscle invasive bladder cancer
- T1: sub epithelial only: low risk
- T2: muscle invasive
- T3a/b through the muscle / invading perivesical fat
- T4a/b invading prostate / pelvic side wall
39
What are the non surgical management options for bladder cancer?
- intravesical chemotherapy: given through catheter to reduce recurrence risk
- intravesical BCG: BCG vaccine used as immunotherapy
40
What is the most common way to divert urine following cystectomy?
- draining urine from the kidney, bypassing the ureters, bladder and urethra
- creating ileal conduit
- urine drains from kidneys > ureters > separated ileum > urostomy bag
41
What are the types of testicular cancer?
- germ cell: seminoma or non seminoma
- Non seminoma: teratoma, yolk sac tumour, choriocarcinoma
- Leydig, and Sertoli cell are rare
42
How does testicular cancer present?
- painless testicular lump: non-tender, hard, irregular
43
What are risk factors for testicular cancer?
- cryptorchidism
- family history
- HIV
- previous testicular cancer
44
How is testicular cancer investigated?
- scrotal ultrasound
- tumour markers: α fetoprotein, β hCG, LDH
45
What is the epidemiology of testicular cancer?
- caucasian males
- aged 15-35
46
How is testicular cancer staged?
- X-ray
- 1: isolated to testicle
- 2: spread to retroperitoneal lymph nodes
- 3: spread to lymph nodes above diaphragm
- 4: metastasised to other organs
47
How is testicular cancer managed?
- radical inguinal orchidectomy
- platinum based chemotherapy
- sperm banking due to possible infertility
48
What are key risk factors for prostate cancer?
- increasing age
- family history
- Black African/Caribbean origin
49
How does prostate cancer present?
- LUTS (similar to benign prostatic hyperplasia)
- haematuria
- erectile dysfunction
- symptoms of metastasis
50
How is prostate cancer diagnosed?
- PSA
- DRE
- MRI
- transrectal ultrasound guided prostate biopsy
- histopathology: Gleason grading
51
What type of cancer is prostate typically?
- adenocarcinoma
- typically occurs in peripheral zone of prostate
- multifocal, occurs with a dominant nodule
- metastasises to lymph nodes, bone, brain, lungs
- firm, hard, irregular and loss of central sulcus in DRE
52
What is the Gleason scoring system?
- tissue grading for prostate cancer
- looks to see how close the tissue is to normality
- grade: how the cancer is likely to behave
53
What is the staging for prostate cancer?
- T1: no palpable tumour on DRE, present on biopsy
- T2: visible nodule, palpable on DRE but confined to prostate
- T3: palpable tumour extending beyond capsule
- T4: invading local structures: sphincter, rectum
54
How is prostate cancer managed?
- surveillance: if early
- external beam radiotherapy: can lead to proctitis
- brachytherapy or hormone therapy
- radical prostatectomy
55
What is glomerulonephritis?
- broad term referring to a group of conditions concerning inflammation and damage to the glomeruli and nephrons
56
What is IgA nephropathy?
- most common cause of primary glomerulonephritis
- abnormality in IgA glycosylation leads to deposition in the mesangium
- leads to haematuria and proteinuria
57
How does IgA nephropathy present and how is it diagnosed?
- episodic macroscopic haematuria
- stimulated by illness e.g. sore throat
- nephrotic syndrome rare
- biopsy
58
How is IgA nephropathy treated?
- controlling BP: ACE-i, ARBs
- steroids and immunosuppression
59
What are the types of erectile dysfunction?
- neurogenic: failure to initiate
- arteriogenic (most common): failure to fill
- venogenic: failure to store
60
What is the epidemiology of erectile dysfunction?
- affects 10% of men aged 40-70
- increasing prevalence with age
61
What is a UTI?
- combination of clinical features and the presence of bacteria in the urine
62
How can UTIs be classified?
- asymptomatic bacteriuria
- uncomplicated
- complicated
63
What is pyuria?
- presence of leucocytes in the urine
- associated with infection
- can have sterile pyuria: finding white cells but not detecting any bacteria e.g. if non-infective cause
64
What are some examples of complicated UTIs?
- pregnant women
- men and children
- catheterised
- immunocompromised or persistent infection
65
Which bacteria commonly cause UTIs?
- E. coli >50%
- Proteus (if repeated suggests renal stones)
- Klebsiella (tend to be catheter associated)
- Enterococci
- Staph. saprophytic (young women)
- S. aureus
- Pseudomonas aeruginosa
66
What is the capacity of the bladder?
- 500ml in women
- 700ml in men
67
What is the aetiology of UTIs?
- catheterisation: cystitis > UTI
- short female urethra
- stones reduce flow and capacity
68
Why does reduced flow cause UTI and what are some causes?
- reduced flow and capacity leads to inflammation and inc frequency
- means bacteria isn't washed away
- renal, ureteric and bladder stones
- obstruction from prostatic hypertrophy
- low urine vol
69
What are symptoms of lower UTIs?
- painful urination (dysuria: stinging, burning)
- haematuria
- cloudy/foul smelling urine
- frequency + urgency
- more localised
70
What are symptoms of upper UTIs?
- haematuria
- fever
- more systemically unwell
71
How are UTIs diagnosed?
- urine sample > dipstick
- microscopy > cultures
- sensitivities to find treatment
72
What factors are considered in urinalysis?
- bloods
- protein
- pH
- glucose and ketones
- leucocytes and nitrates
73
What are the types of urine sampling?
- MSU: midstream urine
- CSU: catheter stream
- clean catch/bag: children
- SPA aspirate: suprapubic
74
What is early morning urine used for?
- looks for TB
- 3x samples
- large volume of urine due to no urination overnight
- higher no. of bacilli on first void of day
75
How are uncomplicated UTIs treated?
- most can be treated empirically with 1st line antibiotics > 3 day course
- inc fluid intake > inc frequency
- voiding pre and post intercourse
- keeping good hygiene
76
What antibiotics are used to treat UTIs?
- avoid broad spectrum
- nitrofurantoin (contraindicated in 3rd trimester pregnancy & low creatinine clearance)/trimethoprim
- 3 days if uncomplicated, 7 if male, pregnant, catheter
77
What is pyelonephritis?
- bacterial infection causing inflammation of kidney
- affects renal parenchyma and soft tissues of renal pelvis + upper ureter
78
What are the causes/risk factors for pyelonephritis?
- young women who are fluid depleted
- structural urological abnormalities
- vesico-ureteric reflux
- diabetes
79
What are the classic triad of symptoms of pyelonephritis?
- loin pain
- fever
- nausea/vomiting
80
What are other signs of pyelonephritis?
- upper UTIs present with systemic illness
- loss of appetite
- haematuria
81
What are the possible causes of pyelonephritis?
- ascending: urethra colonised with bacteria
- haematogenous: S. aureus or Candida
- lymphatic spread is rare
82
How is pyelonephritis investigated?
- abdo exam: loin and renal angle tenderness
- bloods inc cultures
- Ultrasound
- Mid stream urine
- urine dipstick: nitrites, leukocytes, blood
83
How is pyelonephritis treated?
- fluid replacement
- IV antibiotics: broad spectrum e.g. co-amoxiclav ± Gentamicin: 1-2 weeks
- drain the obstructed kidney
- catheter and analgesia
84
Where do stones occur in the urinary tract?
- anywhere from collecting duct to external urethral meatus
- renal and ureteric stones in upper urinary tract
- bladder, prostatic and urethral stones in lower
85
What are the causes of urinary tract stones?
- congenital: due to stasis of urine
- acquired: obstruction, trauma and reflux
- urinary: calcium, oxalate, urate, cystine
- dehydration
- infection
86
What are urinary tract stones made of?
- crystals of normal urinary constituents
- Most are calcium based with oxalate and phosphate
- some from uric acid
87
How can stones be prevented?
- over hydration (based on urine output)
- low salt diet
- healthy protein and normal dairy intake
- reduce BMI and keep an active lifestyle
88
What are the symptoms of urinary tract stones?
- loin pain (radiating to groin)/flank pain
- reduced urine output
- renal colic
- UTI symptoms: dysuria, urgency, frequency
- recurrent UTIs
- haematuria
89
What is testicular torsion?
- twisting of the spermatic cord and rotation of the testicle which cuts off the blood supply
- can lead to ischaemia, necrosis and infertility
90
What is the epidemiology and aetiology of testicular torsion?
- typically occurs in teenage boys
- triggered by activity e.g. sport
- Bell-clapper deformity: absence of fixation between testicle and tunica vaginalis
91
What is the presentation of testicular torsion?
- acute, rapid onset of unilateral testicular pain
- abdo pain and vomiting
- firm, swollen testicle
- testicle lying high and horizontal
- absent cremasteric reflex
92
How is testicular torsion investigated?
- doppler ultrasound to rule out epididymitis (but can delay surgery)
- absent cremasteric reflex
- surgical exploration mandatory as urological emergency
93
How is testicular torsion managed?
- surgery
- surgical exploration of scrotum
- orchiopexy (correction of position)
- orchidectomy (removal) if necrosis
94
What is benign prostatic hyperplasia?
- hyperplasia of the stromal and epithelial cells of the prostate
95
How is BPH investigated?
- international prostate symptom score (IPSS)
- DRE
- PSA
- urine dipstick and bladder diary
96
What can cause a raised PSA?
- prostate cancer
- BPH
- prostatitis
- UTI
- vigorous exercise
- recent ejaculation or prostate stimulation
97
How is BPH treated?
- α blockers e.g. tamsulosin relaxes smooth muscle
- 5-α reductase inhibitors reduce size of prostate: convert testosterone to DHT e.g. finasteride
98
What is felt in a prostate exam that differentiates BPH and cancer?
- BPH: smooth, symmetrical, slightly soft with central sulcus
- cancer: hard, asymmetrical, irregular, loss of central sulcus
99
What is an epididymal cyst?
- occur at head of epididymis (top of testicle)
- fluid filled sac
- soft, round lump - separate from testicle
- harmless
100
What is a hydrocele?
- collection of fluid in tunica vaginalis
- can be idiopathic
- cause: cancer, torsion, epididymo-orchitis, trauma
101
How does a hydrocele present?
- testicle palpable within hydrocele
- painless and soft scrotal swelling
- irreducible and no bowel sounds
- transilluminated by torch
102
What is a varicocele?
- veins in pampiniform plexus become swollen
- veins drain into testicular vein and regulate temp in testes
- caused by inc resistance in testicular vein/incompetent valves
- 90% occur in LHS
103
How does a varicocele present?
- throbbing pain, dragging sensation
- more prominent on standing and disappears when lying down
- scrotal mass that feels like bag of worms
104
How are varicoceles investigated?
- US with doppler imaging
- semen analysis
- hormonal tests
105
What complications can arise from varicoceles?
- testicular atrophy
- reduction in size and function of testicle
- infertility/impaired fertility due to temperature disruption
106
What diseases are included in an STI screen?
- chlamydia
- gonorrhoea
- syphilis
- HIV
107
What is the national chlamydia screening programme?
- screens every sexually active person under 25 for chlamydia annually or when they change sexual partner
- positive cases retested after 3 months
108
What is the public health response to gonorrhoea?
- referral to GUM clinic for testing, treatment and contact tracing
- treatment with ciprofloxacin
- NAAT testing to check if cured due to antibiotic resistance
109
How is syphilis managed?
- full STI screen
- advice and contact tracing
- deep IM dose of benzathine benzylpenacillin
110
How is syphilis tested for?
- antibody testing for Abs to T. palladium
- dark field microscopy and PCR
111
How is syphilis transmitted?
- Oral, vaginal or anal sex
- Vertical transmission
- IV drug use
- Blood transfusions (rare)
112
What is nephritic syndrome?
- a group of symptoms
- haematuria (smoky coloured urine)
- oliguria
- proteinuria
- fluid retention
113
What is Goodpasture's syndrome?
- rare, genetic, autoimmune condition
- glomerulonephritis and alveolar haemorrhage with circulating anti-GBM antibodies
114
What is post streptococcal glomerulonephritis?
- patients under 30 y/o
- occurs 1-3 weeks after streptococcal (S. pyogenes) infection
- patients develop a nephritic syndrome and usually have a full recovery
115
What are the types of prostatitis?
- acute bacterial: rapid onset
- chronic: symptoms last > 3 months
- chronic bacterial
116
How does chronic prostatitis present?
- pelvic pain
- LUTS
- sexual dysfunction
- pain with bowel movements
- tender and enlarged prostate
117
How is chronic prostatitis managed?
- α blockers (tamsulosin)
- analgesia
- antibiotics
- laxatives for pain during bowel movement
118
How is prostatitis investigated?
- urine dipstick testing
- urine microscopy, cultures and sensitivities
- chlamydia and gonorrhoea NAAT testing
119
What is epididymo-orchitis and what are the causes?
- inflammation of the epididymis and testicle on one side
- E. coli, chlamydia trachomatis, neisseria gonorrhoea, mumps
120
What is the aetiology of nephrotic syndrome?
- minimal change disease
- focal segmental glomerulosclerosis
- membranous nephropathy
121
What is the triad of nephrotic syndrome symptoms?
- proteinuria >3g/24hr
- hypoalbuminaemia <30g/L
- oedema
122
What is the management of nephrotic syndrome?
- high dose steroids
- low salt diet
- diuretics
- albumin infusions
- ACE-i
123
What are the genetics and epidemiology behind autosomal dominant polycystic kidney disease?
- mutation in PKD1/2 gene on chromosome 16
- more common in males, presents age 20-30
124
What is the presentation of ADPKD?
- cystic enlargement of collecting ducts
- liver cysts
- intracranial aneurysms: subarachnoid haemorrhage
- abdo pain ± haematuria
- bilateral flank pain
125
What is the pathophysiology behind the presentation of ADPKD?
- PKD 1 + 2 code for polycystin (Ca channel)
- when filtrate passes, channels open and calcium influx inhibits excessive growth
- PKD mutation: Ca reduced so excess cilia growth > cysts
126
How is ADPKD diagnosed and treated?
- kidney USS
- treat hypertension (ACE-i)
- treat end stage renal failure (transplant)
- laparoscopic cyst removal
127
What are the genetics behind ARPKD?
- mutation of PKDH1 on chromosome 6
- codes for proteins creating tubules and healthy epithelial tissue
128
What is the pathophysiology behind ARPKD?
- oligohydraminos is lack of amniotic fluid
- leads to Potter syndrome
- leads to underdeveloped lungs and resp failure
129
What are the symptoms of ARPKD?
- cystic enlargement of collecting ducts
- oligohydraminos
- pulmonary hyperplasia
- congenital liver fibrosis
- Potter syndrome
130
What is Potter syndrome?
- dysmorphic features
- underdeveloped ear cartilage and low set ears
- flat nasal bridge
- skeletal abnormalities
131
What is the extrarenal presentation of ARPKD?
- liver failure
- portal hypertension
- progressive renal failure
- hypertension
- chronic lung disease
132
What is chronic kidney failure?
a permanent and progressive reduction in kidney function
133
What are aetiologies of chronic kidney failure?
- diabetes
- hypertension
- age
- glomerulonephritis
- PKD
- meds: NSAIDs, PPIs, lithium
134
What are risk factors for chronic kidney failure?
- older age
- diabetes
- hypertension
- smoking
- nephrotoxic medication
135
What is the pathophysiology behind chronic kidney disease?
- damaged nephrons > reduced GFR
- inc burden on remaining nephrons
- compensatory RAAS to inc GFR causes inc transglomerular pressure and damages basement membrane selectiveness
- leads to proteinuria and haematuria
- mesangial scarring
136
What is the presentation of chronic kidney disease?
- pruritus
- loss of appetite
- nausea
- oedema
- muscle cramps
- hypertension
- pallor
137
What investigations are done in chronic kidney disease?
- eGFR with U&E: 2 tests 3 months apart
- urine dipstick: haematuria
- albumin:creatinine >3mg/mmol
- renal USS
138
What is the criteria for chronic kidney disease?
eGFR <60mL/min/1.73m^2
139
What is the management of chronic kidney disease?
- treat diabetes, htn, oedema and glomerulonephritis
- exercise and dietary advice
- atorvastatin for prevention of CVD
140
How is anaemia of chronic disease treated?
- IV/oral iron and erythropoietin
141
What are the 5 stages of chronic renal disease?
- G1 = >90
- G2 = 60-89
- G3a = 45-59
- G3b = 30-44
- G4 = 15-29
- G5 = <15 (end-stage renal failure)
142
What is the pathophysiology behind renal bone disease?
- high serum phosphate due to reduced excretion and low vit D > less calcium absorbed
- 2º hyperparathyroidism > inc osteoclast activity
143
What are the features of renal bone disease?
- osteomalacia
- osteoporosis
- osteosclerosis
144
Where do renal stones most commonly get stuck?
- vesico-ureteric junction
145
What are the common complications of renal stones?
- obstruction > AKI
- infection > obstructive pyelonephritis
146
What is the cause of renal stones?
- hypercalcaemia is a common cause esp when paired with low urine output
147
What types of kidney stones most commonly occur?
- calcium oxalate (80%)
- calcium phosphate
- uric acid, struvite, cystine
148
How do renal stones present?
- unilateral loin to groin pain
- colicky pain
- haematuria
- nausea, vomiting
- reduced urine output
- patient can't lie still
149
What investigations are done for renal stones?
- urine dipstick: haematuria
- bloods: FBC, U&Es
- KUB CT
150
What is the management of renal stones?
- NSAIDs
- extracorporeal shock wave lithotripsy
- percutaneous nephrolithiotomy
- tamsulosin can be used to help passage
151
What are the NICE guidelines for the prevention of renal stones?
- inc oral fluid intake (2-3L/day)
- normal calcium intake (low intake inc risk)
- lower oxalate intake (spinach, beetroot, nuts)
152
Which medications can be used to prevent renal stones?
- potassium citrate
- thiazide diuretics
153
What is membranous glomerulonephritis?
- bimodal peak age 20 and 60
- IgG and complement deposits on basement membrane
- usually idiopathic
154
How is glomerulonephritis/nephritic/nephrotic syndrome treated?
- immunosuppression
- blood pressure control (ACE-i or ARBs)
- furosemide if oedema
155
How is glomerulonephritis/nephritic/nephrotic syndrome investigated?
- renal biopsy
- to check for minimal change disease
156
What is the pathophysiology behind nephrotic syndrome?
- basement membrane in glomerulus becomes highly permeable to protein
- proteins leak from blood > urine
- leads to frothy urine
157
What is focal segmental glomerulosclerosis?
- tissue scarring in glomerulus
- light microscope shows segmental sclerosis
- treated by corticosteroids
158
What are the investigations done in nephrotic syndrome?
- light microscopy
- electron microscopy
159
What is seen on electron microscopy in minimal change disease and membranous nephropathy?
- MCD: podocyte effacement + fusion
- MN: subpodocyte immune complex deposition
