Renal / Urology

Question 1

UTI - def, RF, path, Sy, Ix, Mx, prevention

Answer 1

Def - growth of >10n5 organisms/ml. Lower=urethra, bladder, prostate. Upper=renal pelvis. 1/3 of women with sy are aseptic (urethral syndrome).

RF - female, sex, spermicide, pregnancy, menopause, any path in urinary tract.

P - E.coli. Minority proteus mirabilis, klebisella neumonia.

Sy - Cystitis - frequency, sysuria, urgency, haematuria, suprapubic pain. Prostatitis - flu-like sy, low backache, few LUTsy, tender prostate.Pyelonephritis - high fevers, rigors, vomiting, loin pain, oliguria.

Ix - urine dipstick, MSU if culture is negative and sy or if complicated case or haematuria.

Mx - 3dys nitrofurantoin 50mg QDS or trimethoprim 200mg BD. 7dys if male, pregnant, complicated.

Question 2

Ureter obstruction - causes, sy, Ix, comp, Mx

Answer 2

C - Bilat hydronephrosis - congenital, BPH/PCa, bladder tumour, pregnancy. Unilat - TCC, urinary calculi, ureteric stricture, extrinsic Ca, retroperitoneal fibrosis (can be autoimmune or secondary to radiotherapy), AAA.

Sy - Loin pain, infective sy, RF if chronic.

Ix - Hydronephrosis on USS, CTKUB. Isotope renogram

Comp - infection, pyonephrosis, HTN, RF.

Mx - if acute drainage via percutaneous nephrostomy or retrograde ureteric stent. If elective treat cause and nephrostomy if function can’t be restored to avoid complications.

Question 3

Benign prostatic hyperplasia - def, Sy, Ix, Mx

Answer 3

D - non-malignant enlargement of prostate due to androgens/hormones. Commonest cause of LUTS in middle/elderly men.

Sy - Storage sy (frequency, urgency, nocturia, incontinence), voiding sy (hesitancy, poor stream, terminal dribbling), incomplete emptying and acute retention. Smooth enlargement of prostate on DRE.

Ix - DRE and serum PSA, U&Es, urine flowmetry and residual volume. If concerns re malignancy transrectal or perineal biopsy

Mx - Medical - alpha-adrenergic antag (tamsulosin) SE - hypotension or 5alpha-reductase inhib SE - loss of libido/ED. Surgical - usually TURP.

Question 4

Renal Ca - Sy, Ix, Mx, Wilms

Answer 4

Path - Usually renal cell carcinoma (adenocarcinoma). Dialysis is a RF.

Sy - may be asy and found on scanning, painless haematuria, groin pain, mass in flank.

Ix - pre and post contrast CT of abdomen and chest. Bloods - HB and ferritin, U&Es, Ca/alk phos if mets.

Mx - surgical nephrectomy, if mets biologic immunotherapy.

Wilms - nephroblastoma childhood tumour presenting with abdo mass and haematuria.

Question 5

Bladder Ca - path, RF, Sy, Ix, Mx

Answer 5

Path - 90% are transitional cell tumours and can affect any part of the urinary tract. Adenocarcinoma is more common where schistosomiasis occurs (E africa).

RF - aromatic hydrocarbons (chemical, dya, rubber, chimney sweeps), smoking.

Sy - painless haematuria, may have painful micturition, renal colic due to clot, retention.

Ix - cystoscopy, MRI/CT for staging.

Mx - surgical - endoscopic resection if small, radical cystectomy/radiotherapy if large.

Question 6

Prostate Ca - Path, Sy, Ix, Mx

Answer 6

Path - adenocarcinoma, most common Ca in men.

Sy - LUTS, Si of mets, may be diagnosed following PR.

Ix - PR and serum PSA, transrectal ultrasound with biopsy, or transperineal (more info). Graded with Gleason score 2-10. Pelvic MRI for mets. Choline PET shows bone mets.

Mx - Localised - if life expectancy <10y (active monitoring of PSA, treat sy) if expectancy >10y (radical prostatectomy, radiotherapy, or brachytherapy (radioactive seeds). If mets - hormonal therapy using LHRH agonists or anti-androgens.

Question 7

Testicular Ca - path, RF, Sy, Ix, Mx

Answer 7

Path - usually germ cell - seminoma or teratoma (NSGCT - non-seminomatous germ cell tumours). Staged with Marsden staging.

RF - testicular maldescent, high oestrogen.

Sy - painless testicular mass, irregular, firm, doesnt transilluminate.

Ix - Testicular USS. CT abdo chest for mets. Bloods - B-HCG/AFP in metastatic teratoma. In children yolk sac (looks like nephron).

Mx - orchidectomy +- radiotherapy to LN. Teratoma is very chemosensitive even in mets.

Question 8

Scrotal swellings - Painless

Cannot get above

Separate and cystic

Separate and solid, bag of worms

Testicular and cystic

Testicular and solid

Answer 8

Cant get above - Direct inguinal hernia - reduce then surgery - mesh or laparoscopic repair.

Seperate and cystic - Epididymal cyct/spermatocele - clear or milky fluid, remove if sy.

Seperate and solid - Varicocele - dilated veins of pampiniform plexus, like bag of worms, associated with subfertility, repair if sy.

Testicular and cystic - Hydrocele - fluid in tunica vaginalis, may be 1’ which usually resolves in 1st year of life or 2’ to trauma/infection/tumour. Testicular USS to rule out Ca. Mx if sy surgery - Jaboulay/Lords.

Testicular and solid - Testicular Ca or Haematocele - blood in tunica vaginalis post trauma, may need drainage.

Question 9

Scrotal swellings - painful

Sudden onset pain and swelling.

Sudden onset severe pain, high testis.

Trauma.

Pain, blue dot.

Pain, known hernia.

Answer 9

Epididymo-orchiditis - caused by chlamydia/gonorrhoea, mumps. Sy - sudden onset tender swelling, dysuria, fever. Ix - first catch urine PCR/MC&S. Mx - if young/STI suspected - doxycycline/ceftriaxone IM if suspect gon, if older treat for UTI with ciprofloxacin.

Testicular torsion - Sy - sudden onset pain in one testis, walking uncomfortable, abdo pain, N/V. Si - tender hot and swollen testis, high and transverse lie. Ix - USS. Mx - orchidopexy or if dead orchidectomy.

Testicular trauma - Ix - USS, Mx - drain haematocele, orchidectomy if severe damage.

Hyatid of Morgagni torsion - Mullerian duct remnant in children, blue nodule under scrotum.

Incarcerated inguinal hernia - Mx - emergency surgery.

Question 10

Chronic kidney disease - Def, cause, Sy, Ix, Mx

Answer 10

Def - 1=GFR >90 but evidence of kidney damage, 2=60-89 with evidence of kidney damage, 3=30-59, 4=15-29, 5=<15.

C - Diabetes, glomerulonephritis (IgA most common), idiopathic, HTN, pyelonephritis and reflux nephropathy. Screen in those at risk.

Ix - U&Es, FBC, glucose, alk phos and PTH (renal osteodystrophy), haemotinics, USS, renal biopsy if unclear cause.

Mx - Treat reversible cause. ACE-i/ARB ever if no HTN, Bone disease - Ca binders, Vit D analogues, Ca supplements. Start statin and aspirin if high CVD risk. Restrict K in diet. Anaemia - iron/B12/folate, EPO if needed (darbepoietin). Acidosis - sodium bicarbonate supplements. Oedema - furosemide, restrict fluid and NA. Restless legs/cramps - check ferritin, clonazepam/gabapentin.

Question 11

Renal stone disease nephrolithiasis - Path, Presentations, Ix, Mx, prevention

Answer 11

Path - Mostly calcium oxalate (spiky radio-opaque), struvite/magnesium ammonium phosphate (large staghorn opaque), fat malabsorption causes oxalate stones. Usually in PUJ, pelvic brim, vesicoureteric junction.

Presentation - Renal colic - excruciating loin to groin pain, N/V, can’t lie still (ddx peritonitis). Renal obstruction - colicky loin pain.
Obstruction of mid ureter (mimics appendicitis), lower ureter (bladder irratibility, pain in scrotum, penile tip/labia), bladder/urethra (pelvic pain, dysuria, strangury (can’t void)).
+- pyelonephritis, pyonephrosis (infected hydronephrosis), haematuria, protaeinuria, sterile pyuria, anuria.

Ix - Spiral CT, USS for hydronephrosis.

Mx - Analgesia - PR DICLOFENAC +-antiemetic, fluids, Abx. If stone <5mm will pass, increase fluid intake. If stones >5mm or not resolving - Medical therapy - nifedipine/tamsulosin. If don’t pass in 48hrs - extracorpeal shockwave therapy, if unsuitable - ureteroscopy using laser/basket, if unsuitable - percutaneous nephrolithotomy, do open if very complex stones. Operate immidiately if severe.

P - Drink plenty, in hypercalcaemia use thiazide to deacrese Ca++, struvite (mx infection) if urate give allopurinol.

Question 12

Renovascular disease - def, cause, sy, Ix, Mx

Answer 12

D - Stenosis of renal artery. Kidney attempts to raise BP to compensate.

C - Atherosclerosis or renal fibromuscular dysplasia in young women.

Sy - HTN resistant to Mx, worstening RF after ACE/ARB, pulmonary oedema, flash pulmonary oedema, renal bruits.

Ix - USS (affected side smaller), CT/MRI.

Mx - aHTSives, angioplasty/stent.

Question 13

Haemolytic uraemic syndrome - cause, Sy, Ix, Mx

Answer 13

C - E. coli O157 affecting young children after uncooked meat.

Sy - Abdo pain, bloody diarrhoea, AKI.

Ix - Haematuria/proteinuria, blood film (fragmented RBC schistocytes), elevated LDH.

Mx - Dialysis.

Question 14

Incontinence - Functional, stress, urge

Answer 14

Functional - non-physiological, caused by immobility or confusion.

Stress - incompetent sphincter, usually after childbirth. Mx - Pelvic floor exercises, ring pessary for prolapse, tension free vaginal tape, duloxetine (SNRI).

Urge - overactive bladder. Ix - incontinence chart, urodynamics (pressure sensors in bladder and rectum when voiding). Mx - bladder training, also antimuscularinics (tolterodine/oxybutynin).

Question 15

AKI - def, cause, Ix, Mx, pulmonary oedema Mx

Answer 15

Def - decrease in RF over hours/days. Urine should be at least 0.5ml/kg/h.

C - Pre-renal (most common) - hypotension and renal artery stenosis. Renal acute tubular necrosis, autoimmune, vasculitis. Post-renal - stones, clots, malignancy, BPH, strictures.

Ix - Creatine is best surrogate marker.

Mx - fluids (euvolaemia), stop nephrotoxic drugs, treat cause, RRT in ITU if necesary. Refer to nephrology if hyperkalaemic.

Pul oedema - Sit up give O2, diamorphine (vasodilator), furosemide.

Question 16

Hyperkalaemia - cause, Ix, Mx

Answer 16

C - RF, hyporaldosteronism/Addisons, rhabdomyolysis, drugs (spironolactone, NSAIDs, ACEi).

Ix - VBG, U&Es, ECG - prolonged PR, peaked T waves, widening QRS, sinusoidal.

Mx - 10ml 10% calcium gluconate until ECG improves, IV insulin and dextrose. Can add bicarb and use salbutamol.

Question 17

Urinary retention - cause, Ix, Mx

Answer 17

Prostate, urethral obstruction, anticholinergics, constipation.

Ix - examine abdomen, DRE, consider renal USS.

Mx - Catheterise, tamsulosin (alpha-blocker). If clot use 3-way catheter. N.B. post-obstructive diuresis - may need fluids.

Question 18

Nephrotic syndrome - Definition, cause, Sy, DDX, Ix, Mx

Answer 18

Def - triad of proteinuria, hypoalbuminaemia, oedema.

C damage to podocyte foot process - primary (minimal change disease, Focal Segmental GS (incIgAneph/VU reflux) or secondary - hepatitis, SLE, diabetic nephropathy, amyloidosis, drugs (NSAIDs).

Sy - pitting oedema, +++protainuria.

DDX - CCF, LF.

Ix - Ref to nephrology, start steroids in children, renal biopsy in adults.

Mx - Furosemide, ACEi/ARB, treat cause. Have increased risk of infection (low IgG), VTE (anticoagulate), hyperlipidaemia (statin).

Question 19

Rhabdomyolysis - def, Cause, Sy, Ix, Mx

Answer 19

D - Skeletal muscle breakdown releasing myoglobin (ppt in tubules blocking them), K+ (hyperkalaemia), CK.

C - ischaemia, trauma, burns, long lie, seizures.

Sy - Sy of cause, red/brown urine.

Ix - CK >1000iU/L, rule out MI.

Mx - Treat hyperkalaemia, fluids to prevent AKI, IV sodium bicarb to alkalinise urine (stabalises myo), dialysis.

Question 20

Glomerulonephritis - Def, cause, Sy, Ix, Mx

Answer 20

Def - imflammation of the glomerulus and nephrons causing HTN, AKI, blood/protein leak.

Cause - split into primary nephrotic (membranous, minimal change, FSGS), primary nephritic (IgA nephropathy), secondary nephrotic (diabetes, SLE, amyloid, hepatitis), and secondary nephritic (post-strep, vasculitis, SLE anti-GBM).

Sy - Nephrotic - mild HTN, proteinuria, milk AKI. Nephritis - severe HTN, haematuria (mild/macro), mod-sev AKI.

Ix - Renal biopsy. Bloods - ANA, ANCA, antidsDNA, anti-GBM.

Mx - aHTSives inc ACEi/ARB, immunosuppression in autoimmune.

Question 21

Acute interstitial nephritis - Def, Cause, Sy, Mx

Answer 21

Def - damage of kidneys by immune reaction to drugs, infections or autoimmune.

Cause - Drugs (NSAIDs, Abx, diuretics, allopurinol, omeprazole, phenytoin), infection (staph, strep), SLE, sarcoid.

Sy - Renal impairment, allergic picture - rash, fever, eosinophilia.

Mx - stop/treat cause, prednisolone 1mg/kg.

Question 22

Renal tubular acidosis - Def, Type 1, Type 2, Type 4, Fanconi syndrome

Answer 22

Def - Metabolic acidosis due to impaired kidney acid secretion. Will present with GI problems (N/V, vomiting, decreased appetite), Kussmaul breathing, shock, kidney stones.

Type 1 RTA (distal) - inability to excrete H+ even in metabolic acidosis. Inherited or acquired (SLE, Sjogrens, drugs - lithium). Sy - rickets/osteomalacia (buffering H+ with Ca), renal calculi and recurrent UTI (high Ca and alkaline urine). Ix - pH urine high despite acidosis. Mx - PO bicarb.

Type 2 (proximal) - bicarbonate leak as not reabsorbed in proximal tubule, hypokalaemia common due to osmotic effect of bicarb. Mx IV bicarb.

Type 4 (hyperkalaemic) - hyporeninaemic hypoaldosteronism causes decreased H/K excretion. Caused by addisons, diabetic nephropathy, nephritis, spironolactone, NSAIDs. Mx - Fludrocortisone and hyperkalaemia Mx.

Fanconi sy - prox tubular dysfunction causing loss of AAs, glucose, phosphate, bicarb in urine. Causes dehydration, metabolic acidosis, osteomalacia, rickets, electrolyte abnormalities. Causes - congenital (cystinosis/Wilsons), heavy metal poisoning, drugs (gent, cisplatin), myeloma, amyloidosis, Sjogrens. Mx - supplement K, bicarb, phosphate and vit D.

Question 23

Amyloidosis - def, types, AL amyloid, Ix, Mx

Answer 23

D - Group of disorders causing extracellular deposits of fibrillar amyloid protein.

Seen in Alzheimers, T2DM, secondary amyloidosis (following chronic inflammation - amyloid A is an acute phase protein). Also AL amyloidosis (primary).

AL amyloid - plasma clone cells produce amyloidogenic mAb causing organ failure. Poor prognosis. Accumulates in kidneys causing nephrotic sy and RF, restrictive cardiomyopathy, neuropathy, macroglossia (big tongue), hepatomegaly, obstruction, periorbital purpura. Mx - melphalan and prednisolone.

Ix - biopsy - congo red stain birefringence.

Mx - supportive / transplant

Question 24

Diabetic nephropathy - path, Mx

Answer 24

P - Glycosylation thickens the mesangiuma and BM causing sclerosis and proteinuria.

Ix - Monitored by the albumin:creatine.

Mx - ACEi/ARB (decrease glom pressure and proteinuria), tight glycaemic control and CVD RF.

Question 25

Myeloma - path, Sy, Mx

Answer 25

P - Excess production of mAb +- light chains which are excreted as Bence Jones protein in urine, the light chains form casts and block the tubules causing acute tubular necrosis.

Sy - AKI, CKD, hypercalcaemia.

Mx - increase fluid intake, may require dialysis or plasma exchange.

Question 26

Retroperitoneal fibrosis - Path, Cause, Ix, Mx

Answer 26

Path - deposition of dense fibrous tissue around aorta and retroperitoneal vessels causing bilateral obstruction of ureters/

Cause - idiopathic (autoimmune), lymphoma. Associated with B-blockers, autoimmune disease, smoking, asbestos.

Ix - USS kidney followed by CT

Mx - Retrograde stent followed by surgery. Low dose steroid supression.

Question 27

Pyonephrosis - def, Ix, Mx

Answer 27

D - Infected hydronephrosis.

Ix - USS combined with signs of infection.

Mx - treat urgently! Time=glomeruli, percutaneous nephrostomy or stent and Abx.

Question 28

PCKD - Def, genetics, Sy, Ix, Mx

Answer 28

Def - Causes renal enlargement with cysts, ESRF by 50s-70s, screening important.

Gen - AD. Recessive variant is much more severe and presents in infancy with renal cysts and hepatic fibrosis.

Sy - Renal enlargement, abdo pain, haematuria, calculi, HTN, ESRF. Also liver cysts, intracranial aneurysms (increased risk of SAH), mitral valve prolapse, ovarian cysts, diverticulosis.

Ix - genetic testing difficult, USS best test. MRangiography best for Berry aneurysms.

Mx - Monitor U&Es, ACEi, transplant for ESRF.

Question 29

Peyronie’s disease - Def, Sy, Mx

Answer 29

Def - Penile plaques for on tunica albuginea causing pain and deformity.

Sy - painful distorted erections, Hx penile trauma, ED.

Mx - Treat ED with sildenafil, colchicine may decrease inflammation, surgery for severe deformations.

Question 30

Phimosis - Def, cause, Mx

Answer 30

Def - Narrowness of the prepuce preventing retraction of the glans.

Cause - phsiological in childhood or may be secondary to Balanitis Xerotica Obliterans or balanoposthitis.

Mx - In child needs no Mx. Early BXO topical steroid. Surgical circumcision and dorsal slit.

Question 31

Paraphimosis - Def, Mx

Answer 31

Def - retracted prepuce constricts lymphatic and venous drainage of glans causing oedema.

Mx - Retract with saline soaked swab, may need LA and surgery.

Question 32

Renal replacement therapy -

Answer 32

Def - Take over renal function, usual eGFR 10mL/min.

Haemodialysis - blood passed over semipermiable membrane in counter flow and negative pressure. Requires arteriovenos fistula.

Peritoneal dialysis - Uses peritoneum as semi-permiable membrane. Insert catheter into peritoneum and slowly infuse osmotic fluid. Risk of peritonitis and eventually ceases to work due to fibrosis. Use Tenckhoff catheter.

Complications - increased CVD due to HTN and Ca/phos dysreg, malnutrition, renal bone disease, immunosuppression, amyloidosis, increased risk of malignancy. Has massive toll of QOL.

Transplant from cardiac death/brainstem death (cardiac worse due to increased warm ischaemic time) or living donor. Immunospuression - induced using basiliximab and mantanence with calcineurin inhibitor (tacrolimus/cyclosporin), azothioprine and pred.