Renal & Urology Flashcards
(154 cards)
1
Q
What is nephrotic syndrome?
A
Triad:
- Proteinuria (>3.5 g/24 hours)
- Hypoalbuminaemia (<30 g/L)
- Peripheral oedema
Hypercholesterolaemia also a common feature
2
Q
What are the causes of nephrotic syndrome?
A
Most commonly caused by minimal change glomerulonephritis in children
However, all forms of glomerulonephritis can cause it
Other causes: DM SCD Amyloidosis Malignancy - lung and GI adenocarcinomas Drugs - NSAIDs Alport's syndrome HIV
3
Q
What are the risk factors for nephrotic syndrome?
A
- Medical conditions that can damage your kidneys - DM, lupus, amyloidosis
- Drugs - NSAIDs, drugs used to fight infections
- Certain infections - HIV, hep B, hep C, malaria
4
Q
Summarise the epidemiology of nephrotic syndrome
A
Usually adults
M:F = 2:1
5
Q
What are the presenting symptoms of nephrotic syndrome?
A
FHx of atopy
FHx of renal disease
Swelling of face, abdo, limbs, genitalia (due to hypoAlb)
Weight gain - due to excessive fluid retention
Fatigue
Foamy urine
Loss of appetite
6
Q
What are the signs of nephrotic syndrome?
A
Oedema: periorbital, peripheral, genital
Ascites: fluid thrill, shifting dullness
7
Q
How is nephrotic syndrome investigated?
A
Urinanalysis - ++++ proteinuria > 3.5g over 24h
- protein looks frothy
Bloods - hypoalbuminaemia + hyperlipidaemia
Tests to identify cause:
- SLE: ANA, anti-dsDNA antibodies
- Infections: ASO titre for group A B-haemolytic streptococcal infection; HBV serology; Plasmodium malariae blood film
- Goodpasture’s syndrome: anti-glomerular basement antibodies
- vasculitides - polyangiitis w granulomatosis, microscopic polyarteritis (check ANCA)
Renal US
Renal biopsy
8
Q
What is AKI?
A
An abrupt loss of kidney function resulting in the retention of urea and other nitrogenous waste products and the dysregulation of extracellular volume and electrolytes
9
Q
Explain the aetiology of AKI
A
May be multifactorial
- Pre-renal:
- Decreased vascular volume: haemorrhage, D+V, burns, pancreatitis
- Decreased CO: cardiogenic shock, MI
- Systemic vasodilation: sepsis, drugs
- Renal vasoconstriction: NSAIDs, ACE-i, ARB, hepatorenal syndrome - Renal:
- Glomerular: glomerulonephritis, acute tubular necrosis
- Interstitial: drug reaction, infection, infiltration (eg sarcoid)
- Vessels: vasculitis, HUS, TTP, DIC - Post-renal:
- Within renal tract: stone, renal tract malignancy, stricture, clot
- Extrinsic compression: pelvic malignancy, prostatic hypertrophy, retroperitoneal fibrosis
10
Q
What are the risk factors for AKI
A
Pre-existing CKD
Age
Male
Comorbidity - DM, CVD, malignancy, chronic liver disease, complex surgery
11
Q
What are the presenting symptoms of AKI?
A
Depends on underlying cause
- Oliguria/anuria (abrupt anuria suggests post-renal obstruction)
- N+V
- Dehydration
- Confusion
12
Q
What are the signs of AKI O/E?
A
- Hypertension
- Distended bladder
- Dehydration
- Postural hypotension
- Fluid overload (in HF, cirrhosis, nephrotic syndrome)
- Raised JVP
- Pulmonary and peripheral oedema
- Pallor, rash, bruising (vascular disease)
13
Q
How is AKI investigated?
A
- Urinanalysis
- Blood - suggests nephritic cause
- Leucocyte esterase and nitrites - UTI
- Glucose
- Protein
- Urine osmolality - Bloods
FBC, film, U+Es, clotting, CRP, virology (hepatitis, HIV) - Immunology
- Serum Igs + protein electrophoresis for multiple myeloma - also look for Bence-Jones proteins in urine
- ANA, anti-dsDNA abs (active lupus) - SLE
- Low omplement levels - active lupus
- Anti-GBM antibodies - Goodpasture’s syndrome
- Antistreptolysin-O antibodies - high after Streptococcal infection - Ultrasound
- Check for post-renal cause
- Look for hydronephrosis - Other imaging
- CXR: pulm oedema
- AXR: renal stones
14
Q
How is AKI managed?
A
Treat the cause
4 main components:
- Protect patient from hyperkalaemia (calcium gluconate)
- Optimise fluid balance
- Stop nephrotoxic drugs
- Consider for dialysis
- Monitor serum Cr, Na, K, Ca, phosphate, glucose
- Identify and treat infection
- Urgent relief of urinary tract obstruction
- Refer to nephrology if intrinsic renal disease suspected
- Renal replacement therapy (RRT) if:
- HyperK/pulm oedema refractory to medical Mx
- Severe metabolic acidaemia
- Uraemic complications
15
Q
What are the possible complications of AKI?
A
Pulmonary oedema Acidaemia Uraemia Hyperkalaemia Bleeding
16
Q
What are the indicators for poor prognosis of AKI?
A
Inpatient mortality varies depending on cause and comorbidities
Age Multiple organ failure Oliguria Hypotension CKD
17
Q
What are the most common causes of AKI
A
- Sepsis
- Major surgery
- Cardiogenic shock
- Other hypovolaemia
- Drugs
- Hepatorenal syndrome
- Obstruction
18
Q
What is the in the KDIGO classification of AKI?
A
Rise in creatinine > 26 micromol/L within 48h
Rise in creatinine > 1.5 x baseline (ie before AKI) within 7 days
Urine output <0.5mL/kg/h for >6 consecutive hours
19
Q
What is the in the KDIGO classification of AKI?
A
Rise in creatinine > 26 micromol/L within 48h
Rise in creatinine > 1.5 x baseline (ie before AKI) within 7 days
Urine output <0.5mL/kg/h for >6 consecutive hours
20
Q
What is amyloidosis?
A
A group of disorders characterised by extracellular deposits of a protein in abnormal fibrillar form, resistant to degradation
AL - primary
AA - secondary
Familial
21
Q
Summarise the epidemiology of amyloidosis
A
UK:
- age-adjusted incidence = 5.1-12.8/million/yr
- 60 new cases annually
- Higher in males
- Mean age of diagnosis = 63
- Higher in Blacks, lower in Asians
- AA = 10% of systemic amyloidosis
22
Q
What are the risk factors for amyloidosis?
A
- Monoclonal gammopathy of undetermined significance (MGUS)
- Inflammatory polyarthropathy - most common AA cause
- Chronic infections –> AA
- IBD (Crohn’s esp.) –> AA
- Familial periodic fever syndromes –> AA
(6. Castleman’s disease - non-cancerous tumours of lymphoid tissue - plasma cell variant –> AA)
23
Q
What are the presenting symptoms of amyloidosis?
A
Fatigue
Extreme weight loss
Dyspnoea on exertion
24
Q
What are the signs of amyloidosis O/E?
A
- Raised JVP
- Lower extremity peripheral oedema (due to hypoalbuminaemia from nephrotic syndrome)
Less so:
- Periorbital purpura (highly specific)
- Macroglossia (highly specific for AL primary)
25
How is amyloidosis investigated?
1. Serum immunofixation
- positive for monoclonal protein in 60% of patients w immunoglobulin light chain amyloidosis
2. Urine immunofixation
- positive for monoclonal protein in 80% of patients w AL
- presence of light chain protein suggestive of multiple myeloma and amyloidosis
3. Immunoglobulin free light chain assay
- abnormal kappa:lambda
- extremely high sensitivity, >95%, for diagnosing AL
4. Bone marrow biopsy
- clonal plasma cells
26
How is amyloidosis investigated?
1. Serum immunofixation
- positive for monoclonal protein in 60% of patients w immunoglobulin light chain amyloidosis
2. Urine immunofixation
- positive for monoclonal protein in 80% of patients w AL
- presence of light chain protein suggestive of multiple myeloma and amyloidosis
3. Immunoglobulin free light chain assay
- abnormal kappa:lambda
- extremely high sensitivity, >95%, for diagnosing AL
4. Bone marrow biopsy
- clonal plasma cells
27
What is benign prostatic hyperplasia?
Slowly progressive nodular hyperplasia of the periurethral (transitional) zone of the prostate gland
28
Summarise the epidemiology of benign prostatic hyperplasia
Common
70% of men > 70 yrs have histological BPH
50% of them experience symptoms
More common in West
More common in Afro-Caribbeans
29
What is the aetiology of benign prostatic hyperplasia?
UNKNOWN
| Link with hormonal changed (androgens)
30
What are the risk factors for benign prostatic hyperplasia?
- Over 50
- FHx
- Non-Asian
- Smoking
31
What are the presenting symptoms of benign prostatic hyperplasia?
```
FUND HIPS - storage and voiding symptoms:
Frequency
Urgency
Nocturia
Dysuria/dribbling
Hesitancy
Incomplete voiding
Poor stream
Smell/odour
```
Acute retention symptoms:
- Sudden inability to pass urine
- Severe pain
Chronic retention symptoms:
- Painless
- Frequency - passage of small volumes
- Nocturia
32
What are the signs of benign prostatic hyperplasia O/E?
DRE: smoothly enlarged prostate w palpable midline groove
Signs of acute retention:
Suprapubic pain
Distended, palpable bladder
Signs of chronic retention:
Large distended painless bladder (vol > 1L)
Signs of renal failure
33
How is benign prostatic hyperplasia investigated?
1. Urinanalysis - pyuria (white cells or pus) - complicated UTI
2. Bloods
PSA - elevated - underlying prostate Ca or prostatitis
U+Es - impaired renal function
3. Midstream urine - MC&S
4. International Prostate Symptom Score
5. Global bother score
6. Volume charting
34
How is benign prostatic hyperplasia managed?
In emergency (acute urinary retention): catheterisation
Conservative (if mild): watchful waiting
Medical:
- selective alpha blocker (tamsulosin) relax smooth muscle of internal sphincter and prostate capsule
- 5a-reductase inhibitors (finasteride) inhibit conversion of testosterone to DHT, can reduce prostate size by 20%
Surgery:
TURP
Open prostatectomy
35
What are the possible complications of benign prostatic hyperplasia?
```
Recurrent UTI
Acute or chronic urinary retention
Urinary stasis
Bladder diverticula
Stone development
Obstructive renal failure
Post-obstructive diuresis
```
36
What is the prognosis of benign prostatic hyperplasia?
- Mild symptoms usually well controlled medically
| - Most patients get significant relief from surgery
37
What is TURP?
Transurethral resection of prostate
38
What are the indications for TURP?
BPH
39
What are the possible complications of TURP?
- Retrograde ejaculation (up into bladder bc internal sphincter is relaxed)
- Haemorrhage
- Incontinence
- TURP syndrome: seizures or CV collapse due to hypervolaemia and hypoNa due to absorption of glycine irrigation fluid)
- Urinary infection
- Erectile dysfunction
- Urethral stricture
40
What are epididymitis and orchitis?
Inflammation of the epididymis or testes
41
Summarise the epidemiology of epididymitis and orchitis
Common
Affects all age groups
Most common 20-30yo
42
What are the aetiologies of epididymitis and orchitis?
Most cases are INFECTIVE in origin
Bacterial:
If <35: Chlamydia, Gonococcus
If >35: mainly coliforms (Enterobacter, Klebsiella)
Rare: TB, syphilis
Viral: mumps
Fungal: Candida if immunocompromised
1/3 are idiopathic
43
What are the risk factors for epididymitis and orchitis?
Diabetes
| Rare: vasculitis (eg Henoch-Scholein purpura)
44
What are the presenting symptoms of epididymitis and orchitis?
- Painful, swollen and tender testis or epididymis
| - Penile discharge
45
What are the signs of epididymitis and orchitis O/E?
- Swollen and tender epididymis or testis
- Scrotum may be erythematous and oedematous
- Pyrexia
- Painful walking
- Eliciting cremasteric reflex may be painful
46
How are epididymitis and orchitis investigated?
1. Urine: dipstick + early morning for Mc&S
2. Bloods:
FBC - high WCC
High CRP
U+Es
3. Imaging: increased blood flow on duplex examination
47
How are epididymitis and orchitis managed?
Medical: ABx
Surgical:
- exploration of testicles if testicular torsion cannot be excluded clinically
- required if abscess develops
48
What are the possible complications of epididymitis and orchitis?
- Pain
- Abscess
- Fournier's gangrene (if infection left untreated and spreads)
- Mumps orchitis could cause testicular atrophy and fertility issues
49
What are the prognoses of epididymitis and orchitis?
Good if treated
| May take up to 2 months for swelling to resolve
50
How does the onset of epididymitis or orchitis differ from that of testicular torsion?
Less acute onset
51
What is chronic kidney disease?
Progressive loss of kidney function over a period of months or years
52
Summarise the epidemiology of CKD
Common
Risk increases with age
Often associated with other diseases, eg CVD
53
What is the aetiology of CKD?
Most common cause in adults = diabetes (1/3 develop KD within 5-10yrs of diagnosis)
HTN = 2nd most common cause
```
Less common causes =
polycystic kidney disease
obstructive uropathy
glomerular nephrotic and nephritic syndromes
membranous nephropathy
lupus nephritis
amyloidosis
rapidly progressive glomerulonephritis
```
54
What are the risk factors for CKD?
DM
HTN
>50
Childhood kidney disease
55
What are the presenting symptoms of CKD?
Often asymptomatic
May be incidental finding of routine blood/urine test
```
Anorexia
N+V
Fatigue
Pruritus
Peripheral oedema
Muscle cramps
Sexual dysfunction
```
56
What are the signs of CKD O/E?
May show signs of underlying disease (eg SLE)
May show complications of CKD (eg anaemia)
```
Skin pigmentation
Excoriation marks
Pallor
HTN
Peripheral + pulmonary oedema
Peripheral vascular disease
```
57
How is CKD investigated?
1. Assessment of renal function: urea, creatinine, isotopic GFR (gold standard)
2. Biochemistry:
- glucose: check for undiagnosed DM and diabetic control
- raised K
- also check Na, HCO3, Ca, PO4
3. Serology:
- antibodies: ANA for SLE< c-ANCA for Wegener's, anti-GBM for Goodpasture's
- hepatitis serology
- HIV serology
4. Urinanalysis:
- check for proteinuria/haematuria
- 24h urine collection
- serum or urine protein electrophoresis - check for multiple myeloma
5. Imaging:
- US to check for structural abnormalities
- CT/MRI
- XR KUB - check for stones
6. Renal biopsy
58
What is a limitation of using creatinine to assess renal function?
Renal function can drop considerably with minimal change in serum creatinine
59
Why is looking at serum urea not ideal to assess renal function
Varies massively depending on hydration status and diet
60
What is glomerulonephritis?
An immunologically mediated inflammation of the renal glomeruli
61
Summarise the epidemiology of glomerulonephritis
Accounts for 25% of cases of chronic renal failure
62
What is the aetiology of glomerulonephritis?
Can result from renal-limited glomerulopathy or from glomerulopathy-complicating systemic disease, eg SLE, vasculitis
1. Glomerular injury caused by inflammation due to leukocyte infiltration, ab deposition, complement activation
2. Idiopathic
3. Infection
4. Systemic inflammatory conditions: vasculitides (SLE, RA< anti-GBM disease, granulomatosis)
5. Drugs: penicillamine, gold sodium thiomalate, NSAIDs, captopril, heroin, mitomycin C, cocaine, anaoblic steroids)
6. Metabolic disorders: DM, HTN, thyroiditis
7. Malignancy: lung, colorectal Ca, melanoma, Hodgkin's lymphoma
8. Hereditary disorders: Fabry's disease, Alport's syndrome, thin basement membrane disease
9. Deposition diseases: amyloidosis, light chain deposition disease
63
What are the risk factors for glomerulonephritis?
```
Group A beta-haemolytic Streptococcus
Respiratory infections
GI infections
HBV, HCV, HIV
Infective endocarditis
SLE
Systemic vasculitis
Cancer: Lymphoma
Lung Ca
Colorectal Ca
```
64
What are the presenting symptoms of glomerulonephritis?
```
Haematuria
Swelling
Polyuria/oliguria
History of recent infection
Generalised vasculitic picture: anorexia, nausea, malaise, skin rash, arthralgia,
Weight loss
Fever
Haemoptysis
Abdo pain
Sore throat
```
65
What are the signs of glomerulonephritis O/E?
```
HTN
Generalised oedema
Anorexia
Skin rash
Fever
Abdo guarding
```
66
How is glomerulonephritis investigated?
1. Bloods: FBC, U+Es, Cr, LFTs (check albumin), lipid profile, complement studies, antibodies - ANA, anti-dsDNA, ANCA, anti-GBM, cryoglobulins
2. Urine:
- MC&S for red cell casts
- 24h collection: Cr clearance and protein
3. Imaging: renal tract US to exclude other pathology (eg obstruction)
4. Renal biopsy for microscopy
5. Investigations for associated conditions: eg HBC, HCV, HIV serology
67
What is hydrocele?
The excessive collection of serous fluid within the tunica vaginalis
68
Summarise the epidemiology of hydrocele
Very common in children in first year of life
Common in older men
69
What is the aetiology of hydrocele?
- Congenital
- Idiopathic
- Tumour
- Infection
- Trauma
- Underlying testicular torsion
- Testicular appendage
70
What are the risk factors for hydrocele?
- Indirect inguinal hernias in children
- Epididymo-orchitis
- Filariasis (in countries of high prevalence)
71
What are the presenting symptoms of hydrocele?
Scrotal swelling
Usually asymptomatic
May complain of pain or urinary symptoms due to underlying cause
72
What are the signs of hydrocele O/E?
Scrotal swelling
Possible to get above swelling
Transilluminates
Difficult to separate swelling from testicle
73
How is hydrocele investigated?
1. US - exclude tumour
2. Urine - dipstick and MSU for infection
3. Bloods - markers of testicular tumours = a-fetoprotein, B-HCG, LDH
74
What is polycystic kidney disease?
Autosomal dominant inherited disorder characterised by the development of multiple renal cysts that gradually expand and replace normal kidney substance, variably associated with extrarenal (liver and CV) abnormalities
75
Summarise the epidemiology of polycystic kidney disease
Most common inherited kidney disorder
Responsible for 10% of end-stage renal failure
Presents at 30-40yrs
20% have no FHx
76
What is the aetiology of polycystic kidney disease?
- 85% caused by mutations in PKD1 on Chr 16
- Membrane-bound multidomain protein involved in cell-cell and cell-matrix interactions
- 15% caused by mutations of PKD2 on Chr 4
77
What are the risk factors for polycystic kidney disease?
FHx of autosomal-dominant PKD
| FHx of cerebrovascular event
78
What are the presenting symptoms of polycystic kidney disease?
May be asymptomatic
Flank pain - may result from cyst enlargement/bleeding, stone, blood clot migration, infection
Haematuria
HTN
Associated w berry aneurysms and may present with SAH
79
What are the signs of polycystic kidney disease O/E?
```
Abdo distension
Enlarged cystic kidneys
Palpable liver
HTN
Signs of chronic renal failure
Signs of associated AAA or aortic valve disease
```
80
How is polycystic kidney disease investigated?
US or CT:
- multiple cysts bilaterally in enlarged kidneys
- liver cysts may be seen
81
What is renal artery stenosis?
Stenosis of the renal artery
82
Summarise the epidemiology of renal artery stenosis
Accounts for 1-5% of HTN
90% of RAS = atherosclerotic RAS
Fibromuscular dysplasia = 10% of RAS
Females 2-10x more likely to have FMD - onset before 30
83
What is the aetiology of renal artery stenosis?
Atherosclerosis (older patients) - widespread aortic disease involving the renal artery ostia
Fibromuscular dysplasia (younger patients):
- unknown aetiology
- may be associated w collagen disorders, neurofibromatosis, Takayasu's arteritis
- may be associated w micro-aneurysms in mid and distal renal arteries
84
What are the risk factors for renal artery stenosis?
Dyslipidaemia
Smoking
DM
Female
85
What are the presenting symptoms of renal artery stenosis?
Hx of HTN < 50
HTN refractory to Tx
Accelerated HTN and renal deterioration on starting ACE-i
Hx of flash pulmonary oedema
86
What are the signs of renal artery stenosis O/E?
HTN
Signs of renal failure in advanced bilateral disease
Renal artery bruits
87
How is renal artery stenosis investigated?
1. Duplex US
2. US measurement of kidney size
3. CT angiogram or MR angiography - risk of contrast nephrotoxicity
4. Digital subtraction angiography = gold standard
5. Renal scintigraphy
88
What is testicular torsion?
Twisting or torsion of the spermatic cord results, initially, in venous outflow obstruction from the testicle, progressing to arterial occlusion and testicular infarction if not correct
A surgical emergency
89
Summarise the epidemiology of testicular torsion
Most common cause of acute scrotal pain in 10-18yo
90
What is the aetiology of testicular torsion?
Intravaginal (most common):
Spermatic cord twists within the tunica vaginalis
Extravaginal (usually in neonates)
Entire testis and tunica vaginalis twist in vertical axis on spermatic cord
Due to incomplete fixation of gubernaculum to scrotal wall allowing free rotation
91
What are the risk factors for testicular torsion?
Imperfectly descended testes
| High investment of tunica vaginalis
92
What are the presenting symptoms of testicular torsion?
Sudden onset severe hemiscrotal pain
Abdo pain
N+V
93
What are the signs of testicular torsion O/E?
- Swollen, erythematous scrotum on affected side
- Swollen testicle will lie slightly higher
- Testicle may lie horizontal
- Thickened cord
- Testicular appendix - visible necrotic lesion on transillumination
94
How is testicular torsion investigated?
Dopper/duplex imaging
- do NOT delay surgery
- arterial inflow reduced in testicular torsion vs increased in epididymo-orchitis
95
How is testicular torsion managed?
- Exploration of scrotum within 6h of onset of symptoms
- After testicle twisted back into place, bilateral orchidopexy performed
- Suture testicle to scrotal tissue to prevent recurrence
- If testicle, orchidectomy performed
96
What are the possible complications of testicular torsion?
Testicular infarction
Testicular atrophy
Infection
Impaired fertility (due to production of anti-sperm antibodies)
97
What is the prognosis of testicular torsion?
From onset, testicle may only survive 4-6 hours
| With prompt surgical intervention, most testicles are salvaged
98
What are urinary tract calculi?
Crystal deposition within the urinary tract
AKA nephrolithiasis
99
Summarise the epidemiology of urinary tract calculi?
```
Common
2-3% of general population
3x more common in males
20-50yos
Bladder stones more common in developing countries
```
100
What is the aetiology of urinary tract calculi?
Many cases are idiopathic
```
Metabolic causes:
HyperCa
Hyperuricaemia
Hypercystinuria
Hyperoxaluria
```
Infection: hyperuricaemia
Drugs: indinavir
101
What are the risk factors for urinary tract calculi?
Low fluid intake
| Structural urinary tract abnormalities (eg horseshoe kidney)
102
What are the presenting symptoms of urinary tract calculi?
```
Often asymptomatic
Severe loin to groin pain
N+V
Urinary urgency, frequency, retention
Haematuria
```
103
What are the signs of urinary tract calculi O/E?
Loin to lower abdo tenderness
No signs of peritonism
Leaking AAA = main differential in older men
Signs of systemic sepsis if there is an obstruction and infection above the stone
104
How are urinary tract calculi investigated?
1. BLOODS
- FBC - high WCC if infection
- U+Es - check renal function
- Ca, urate, phosphate
2. URINE
- Dipstick - haematuria
- MC&S - infection
3. IMAGING
- XR KUB - radio-opaque kidney stones
- IV urography - visualisation of kidneys and ureters
- US - may show hydronephrosis and hydroureter
- Non-enhanced spiral CT - image stones
- Isotope radiography - assess kidney function
105
How are urinary tract calculi managed?
Acute:
- analgesia
- bed rest
- fluid replacement
- urine collection to try and retrieve any passed stone
Obstructed, infected kidney = emergency - relieve obstruction
Removal of calculi:
- Urethroscopy +- JJ stent
- Extracoporeal Shock-Wave Lithotripsy (ESWL)
- Percutaneous Nephrolithotomy (PCNL)
Treatment of cause:
- parathyroidectomy if hyperCa due to hyperPT
- allopurinol if hyperuricaemia
Advice:
- increase oral fluid intake
106
What are the possible complications of urinary tract calculi?
Infection (pyelonephritis)
Septicaemia
Urinary retention
107
What is the prognosis of urinary tract calculi?
Good
However infection of calculus could lead to irreversible renal scarring
Recurrence of 50% over 5 years
108
Where are bladder stones more common?
In developing countries
109
Where are upper UT stones more common?
In industrialised countries
110
What is a UTI?
The presence of a pure growth of > 10^5 organisms per mL of fresh MSU (lab - not necessity)
111
How can UTIs be classified?
Lower UTI - affecting urethera (urethritis), bladder (cystitis) or prostate (prostatitis)
Upper UTI - affecting renal pelvis (pyelonephritis)
Uncomplicated UTI - normal renal tract and function
Complicated UTI - abnormal renal/genitourinary tract, voiding difficulty/obstruction, reduced renal function, impaired host defences, virulent organism (eg S. aureus)
112
What is the aetiology of UTI?
```
Most caused by Escherichia Coli
Also:
- Staphylococcus saprophyticus
- Proteus mirabilis
- Enterococci
```
113
What are the risk factors for UTI?
```
Female
Sexual intercourse
Exposure to spermicide
Pregnancy
Menopause
Immunosuppression
Catheterisation
Urinary tract obstruction
Urinary tract malformation
```
114
What are the presenting symptoms of UTI?
Cystitis:
- frequency
- urgency
- dysuria
- haematuria
- suprapubic pain
Prostatis:
- flu-like symptoms
- low backache
- few urinary symptoms
- swollen or tender prostate on PR
Acute pyelonephritis:
- high fever
- rigors
- vomiting
- loin pain and tenderness
- oliguria (if AKI)
115
What are the signs of UTI O/E?
```
Fever
Abdo or loin tenderness
Foul-smelling urine
Distended bladder (occasionally)
Enlarged prostate (if prostatits)
```
116
How is UTI investigated?
Urine dipstick - positive leukocyte esterase and nitrites
Urine microscopy - leukocytes if infection
Urine culture - exclude diagnosis or if patient failed to respond to empirical abx
US - rule out obstruction
Bloods - FBC, U+Es, CRP, cultures if systemically unwell and risk of urosepsis
117
How is UTI managed?
Uncomplicated:
Trimethoprim or nitrofurantoin
3-6 days
Men may need longer course
Alternatives:
Co-amoxiclav or cefalexin
118
What are the possible complications of UTI?
```
Ascending infection can lead to:
Pyelonephritis
Perinephric and intrarenal abscess
Hydronephrosis or pyonephrosis
AKI
Sepsis
```
Prostatic involvement (eg prostatitis) in men is common
119
What is the prognosis of UTI?
Good w appropriate treatment
120
What atypical organisms can cause UTI?
Usually in immunocompromised individuals
Klebsiella
Candida albicans
Pseudomonas aeruginosa
121
What is varicocoele?
Dilated veins of the pampiniform plexus forming a scrotal mass
122
Summarise the epidemiology of varicocoele
Unusual in boys under 10yo
Incidence increases after puberty
Incidence: 15% in general population
Associated w infertility
123
What is the aetiology of varicocoele?
Due to venous incompetence
124
What are the presenting symptoms of varicocoele?
```
Usually asymptomatic
Only 2-10% have symptoms
Scrotum feels like bag of worms
Scrotal heaviness
Incidental finding at examination
```
125
What are the signs of varicocoele O/E?
Must be standing for examination
Side of scrotum w varicocoele hangs lower
Swelling may reduce when lying down
Valsalva manoeuvre whilst standing will increase dilatation
Cough impulse
126
How is varicocoele investigated?
Sperm count
| Colour Doppler scan
127
Why is varicocoele more common on the left?
More common on left (80-90%) bc of:
- Angle at which left testicular vein meets left renal vein
- Lack of effective valves between LTV and LRV
- Increased reflux from compression of renal vein (between superior mesenteric artery and aorta)
128
Why is varicocoele more common on the left?
More common on left (80-90%) bc of:
- Angle at which left testicular vein meets left renal vein
- Lack of effective valves between LTV and LRV
- Increased reflux from compression of renal vein (between superior mesenteric artery and aorta)
129
What is renal cell carcinoma?
Renal malignancy arising from the renal parenchyma/cortex
130
Summarise the epidemiology of renal cell carcinoma
Majority (85%) of renal malignancies = RCC
Accounts for 2-3% of all new cancers globally
6th-8th most common adult malignancy
Of true RCCs, 80% = renal cell adenocarcinomas of clear cell histology, 12-15% are papillary tumours
Incidence rates increasing in Europe and NA, especially among women and Africans
2x many men vs women
Men have worse prognosis as present later
131
What are the risk factors for renal cell carcinoma?
```
Smoking
Male
55-84yo
Living in developed country
Black or native American
Obesity
HTN
FHx (4x)
Hx of hereditary syndrome (VHL syndrome)
Hx of dialysis
Occupational exposure to toxins: asbestos, cadmium, petroleum
High parity
Ionising raditaion syndrome
```
132
What are the presenting symptoms for renal cell carcinoma?
50% asymptomatic
Haematuria
<10% triad: haematuria + flank pain + palpable abdominal mass = locally advanced disease
Non-specific systemic: fever, weight loss, sweats, pallor, cachexia, myoneuropathy
133
What are the signs of renal cell carcinoma O/E?
```
Flank tenderness
Palpable abdominal mass
Fever
Cachexia
Hepatic dysfunction: ascites, hepatomegaly, spider angiomata
Myoneuropahty
Lower limb oedema
```
134
How is renal cell carcinoma investigated?
FBC: paraneoplastic syndrome = reduced Hb or elevated RBC
LDH: advanced RCC = >1.5x upper limit of normal
Corrected Ca: advanced RCC = >2.5 mmol/L
LFTs: metastatic disease/paraneoplastic syndrome = abnormal
Coagulation profile: PNPS = elevated PT
Creatinine: elevated w reduced creatinine clearance
Urinanalysis: haematuria and/or proteinuria
Abdopelvis US: abnormal renal cyst/mass, lymphadenopathy, and/or other visceral metastatic lesions
CT abdopelvis: as for US; contrast enhanced
MRI abdopelvis: as for US but modality of choice where contrast dye CI (renal insufficiency/allergy)
135
Summarise the epidemiology of bladder cancer
9th in worldwide cancer incidence
Egypt, Western Europe, and NA have highest incidence rates
Asian countries have lowest rates
More than 90% of new cases occur in people >55yo
136
What are the risk factors for bladder cancer?
```
Smoking
Exposure to chemical carcinogens
Age >55
Pelvic radiation
Systemic chemotherapy: cyclophosphamide
Schistosoma infection
Male 4x
Chronic bladder inflammation: stones, UTI
FHx
```
137
What are the presenting symptoms of bladder cancer?
Haematuria (gross, painless, present throughout entire stream)
Dysuria
Urinary frequency
138
How is bladder cancer investigated?
Urinanalysis: RBC casts and crenated red cells w glomerular bleeding; gross/microscopic haematuria; pyuria
Urine cytology: +ve
Renal and bladder US/CT urogram.: tumour/obstruction
Cystoscopy: visualises tumours and path diagnosis
FBC: normal/mild anaemia
139
What is prostate cancer?
A malignant tumour of glandular origin, situated in the prostate
140
Summarise the epidemiology of prostate cancer
6th leading cause of cancer mortality in US
Adenocarcinoma is most commonly diagnosed non-cutaneous neoplasm of men in US
Median age at diagnosis = 66
Australia and New Zealand = highest rates
141
What is the aetiology of prostate cancer?
Unknown but theorised:
- High-fat diet
- Genetic factors
- ?Hormonal influence
142
What are the risk factors for prostate cancer?
>50yo
Black
NA or northwest European descent
FHx
143
What are the presenting symptoms of prostate cancer?
Nocturia
Urinary frequency
Urinary hestitancy
Dysuria
144
What are the signs of prostate cancer O/E?
Asymmetrical, nodular prostate on DRE
145
How is prostate cancer investigated?
Serum PSA > 4 micrograms/L or >4 nanograms/mL
Testosterone: normal
LFTs: normal
FBC: normal
Renal function; normal
Prostate biopsy: malignant cells
146
Summarise the epidemiology of testicular cancer
Most common malignancy in young adult men (20-34yo)
147
What are the risk factors for testicular cancer?
```
20-34yo
Cryptochidism
Gonadal dysgenesis
FHx
Personal Hx
White
```
148
What are the presenting symptoms of testicular cancer?
```
Painless swelling in one testicle
Change in shape/texture of testicle
Increased firmess of testicle
Difference between testicles
Dull ache/sharp pain in testicles or scrotum
Feeling of heaviness in scrotum
```
149
What are the signs of testicular cancer O/E?
Painless (85%) testicular mass
150
How is testicular cancer investigated?
US (colour Doppler) of testis: testicular mass
CT abdopelvis: enlarged retroperitoneal LNs
Serum beta-hCG: elevated >0.7 IU/L in choriocarcinoma
Serum alpha-fetoprotein: >25 microgram/L
Serum LDH: >25 U/L
151
How is testicular cancer investigated?
US (colour Doppler) of testis: testicular mass
CT abdopelvis: enlarged retroperitoneal LNs
Serum beta-hCG: elevated >0.7 IU/L in choriocarcinoma
Serum alpha-fetoprotein: >25 microgram/L
Serum LDH: >25 U/L
152
What is urinary catheterisation?
Insertion of a latex, polyurethane or silicone tube into a patient's bladder via the urethra
153
What are the indications for urinary catheterisation?
Intermittent:
- Sterile urine sample
- Relief from bladder distention
- Bladder decompression
- Measure residual urine
- Mx of pt w SCI, NM degeneration, or incompetent bladder
Short-term indwelling:
- Post surgery and in critically ill patients to monitor output
- Acute urinary retention: BPH, blood clots
- Instillation of meds into bladder
- Pelvic/abdo surgery repair of bladder, urethra, surrounding structures
Long-term indwelling:
- Refractory bladder outlet obstruction
- Neurogenic bladder w UR
- Prolonged and chronic UR
- Promote healing of perineal ulcers
154
What are the possible complications of urinary catheterisation?
```
Long-term catheter: UTI
Sepsis
Urethral injury
Skin breakdown
Bladder stones
Haematuria
Bladder cancer
```
