Renal & Urology Flashcards
(144 cards)
1
Q
What is benign prostatic hyperplasia?
A
Lower urinary tract symptoms (LUTS) caused by bladder outlet obstruction. There are two components:
- A static component related to an increase in benign prostatic tissue narrowing the urethral lumen
- A dynamic component related to an increase in prostatic smooth muscle tone mediated by alpha-adrenergic receptors
2
Q
What is the aetiology of benign prostatic hyperplasia?
A
Hyperplasia of the epithelial and stromal compartments, particularly in the transitional zone, may be attributed to various factors including shifts in age-related hormonal changes creating androgen/oestrogen imbalances
3
Q
What is the epidemiology of benign prostatic hyperplasia?
A
The prevalence of histological BPH increases with age, affecting approximately 42% of men between the ages of 51 and 60 years and 82% of men between the ages of 71 and 80 years
4
Q
What are the presenting symptoms of benign prostatic hyperplasia?
A
Storage symptoms: -Frequency -Urgency -Nocturia Voiding symptoms: -Weak stream -Hesitancy -Intermittency -Straining -Incomplete emptying -Post-void dribbling
5
Q
What are the signs of benign prostatic hyperplasia on physical examination?
A
Assess severity of symptoms and impact on life
PR exam: may demonstrate prostate volume ≥30 g, nodules or tenderness suspicious of prostate cancer or prostatitis
6
Q
What are the appropriate investigations for benign prostatic hyperplasia?
A
MSU- urinalysis: pyuria (presence of pus)
Bloods: U&Es-kidney dysfunction
Ultrasound: hydronephrosis ( swollen kidney as the result of a build-up of urine), mass, urolithiasis (formation of stony concretions in the bladder or urinary tract)
Rule out cancer:
-PSA (prostate specific antigen): elevation greater than age guideline, non-specific for BPH
-Transrectal use and biopsy
7
Q
What is the management for benign prostatic hyperplasia?
A
Main goal is to improve lower urinary tract symptoms (LUTS) in order to improve quality of life:
Lifestyle:
-Avoid caffeine, alcohol (to reduce urgency/nocturia)
-Relax when voiding and void twice in a row to aid emptying
-Control urgency by practising distraction methods (eg breathing exercises)
Medical therapy: (useful in mild disease, and while awaiting surgery)
-Alpha blockers are 1st line (eg tamsulosin 400mcg/d also alfuzosin, doxazosin, terazosin). Reduces smooth muscle tone (prostate and bladder)
-5 alpha-reductase inhibitors: can be added, or used alone, eg finasteride 5mg/d (reduce conversion of testosterone to the more potent androgen dihydrotestosterone)
Surgical therapy:
-Transurethral resection of prostate (TURP) ≤14% become impotent
-Transurethral incision of the prostate (TUIP) involves less destruction than TURP, and less risk to sexual function, gives similar benefit. Relieves pressure on the urethra. Maybe best surgical option for those with small glands <30g
- Retropubic prostatectomy is an open operation (if prostate very large)
-Transurethral laser-induced prostatectomy (TULIP) may be as good as TURP
-Robotic prostatectomy is gaining popularity as a less traumatic and minimally invasive treatment option
8
Q
What are the complications of benign prostatic hyperplasia?
A
UTI Haematuria Bladder stones Acute urinary retention Renal insufficiency Sexual dysfunction Overactive bladder
9
Q
What is the prognosis of benign prostatic hyperplasia?
A
The majority of patients with BPH can expect at least moderate improvement of their symptoms with a decreased bother score and improved quality of life
*some patients (20%) may still see a clinical progression For some the symptoms/ SE may affect sexual wellbeing including erectile function
10
Q
What is acute kidney injury (AKI)?
A
An acute decline in kidney function, leading to a rise in serum creatinine and/or a fall in urine output
11
Q
What is the aetiology of acute kidney injury (AKI)?
A
AKI may be due to various insults such as impaired kidney perfusion, exposure to nephrotoxins, outflow obstruction, or intrinsic kidney disease
12
Q
What are the risk factors of acute kidney injury (AKI)?
A
Advanced age
Underlying kidney disease
Diabetes Mellitus
Sepsis- may result in acute tubular necrosis, infectious glomerulonephritis, pre-kidney AKI from hypotension, or drug-induced injury from medications
Nephrotoxins e.g. aminoglycosides, NSAIDs, vancomycin
13
Q
What are the pre-renal causes of an AKI?
A
Reduced renal perfusion:
Shock (hypovolaemic, septic, cardiogenic)
hepatorenal syndrome (liver failure)
14
Q
What are the renal causes of an AKI?
A
Acute tubular necrosis- ischaemia, drugs and toxins
Acute glomerulonephritis
Acute interstitial nephritis- NSAIDs, penicillins, sulphonamides
Vessel obstruction- Renal artery/vein thrombosis, cholesterol emboli, vasculitis
Other causes:
myeloma, haemolysis, nephropathy
15
Q
What are the post renal causes of an AKI?
A
Stone
Tumour (pelvic, prostate, bladder)
Blood clots
Retroperitoneal fibrosis
16
Q
What is the epidemiology of AKI?
A
Incidence of 1800 per million
17
Q
What are the presenting symptoms of AKI?
A
Usually asymptomatic Lower urinary tract symptoms- urgency, frequency or hesitancy Low urine output (oliguria) Malaise Anorexia Nausea and vomiting Pruritus (itching) Drowsiness Convulsions, coma (caused by uraemia)
18
Q
What are the signs of acute kidney injury (AKI) on physical examination?
A
Oedema
19
Q
What are the appropriate investigations for AKI and interpret the results?
A
1st line:
Basic metabolic profile- an acutely rising creatinine may be the only sign. Acutely elevated serum creatinine, high serum potassium, metabolic acidosis.
Serum potassium- elevated in hyperkalaemia
LFTs will be deranged in hepatorenal syndrome
FBC- leukocytosis may suggest an infection
CRP- elevated in infection and vasculitis
Blood culture- Positive for bacterial pathogen
Urinalysis- RBCs, WBCs, cellular casts (glomerulonephritis), proteinuria, positive nitrite, and leukocyte esterase
CXR- signs of infection or fluid
ECG- changes associated with hyperkalaemia (tented T waves)
Others:
Renal ultrasound- check for an obstructive cause
20
Q
What is the management plan for acute kidney injury?
A
1.Assess hydration and fluid balance:
Pulse rate, lying and standing BP, JVP, skin turgor, chest auscultation, peripheral oedema, central venous pressure, fluid and weight charts. ECG monitoring (hyperkalaemia)
- If hypovolaemic (+ hyperkalaemia)
- fluid resuscitation
- review medications and stop nephrotoxins
- identify and treat underlying cause
others:
- vasoactive drug
- blood transfusion - If hypervolaemic (+ pulmonary oedema and hyperkalaemia)
- loop diuretic (under specialist supervision) and sodium restriction
- identify and treat underlying cause
consider: renal replacement therapy
Metabolic acidosis (if pH < 7.2): 50–100 mL of 8.4% bicarbonate via central line over 15–30 min
21
Q
What medications can cause an AKI?
A
Acute tubular necrosis (ATN): paracetamol, aminoglycosides, amphotericin B (anti-fungal), NSAIDs, ACE-inhibtors, lithium
Acute interstitial nephritis: NSAIDs, penicillins, sulphonamides
Others: opioids, other antibiotics e.g. trimethoprim, vancomycin
22
Q
What is the treatment for acute pulmonary oedema?
A
P- positioning (sit up)
O- oxygen
D- diuretic (furosemide) and fluid restriction
M- (dia)morphine
A- anti-emetics
N- nitrates (GTN infusion if SBP >110, or 2 puffs GTN spray if SBP >90)
23
Q
What are the possible complications of acute kidney injury (AKI)?
A
Common and life-threatening: Hyperkalaemia Sepsis Metabolic acidosis Pulmonary oedema Hypertension. Less common: Gastric ulceration, bleeding (platelet dysfunction), muscle wasting (hypercatabolic state), uraemic pericarditis, uraemic encephalopathy, acute cortical necrosis
24
Q
What is the prognosis for patients with acute kidney injury (AKI)?
A
Acute tubular necrosis has biphasic recovery starting with oliguria then leading to polyuria (resulting from regeneration of the tubular cells)
Prognosis depends on the number of other organs involved, e.g. heart, lung
Many of those with ATN recover
Acute cortical necrosis may cause hypertension and chronic renal failure
25
What is amyloidosis?
A (heterogenous) group of diseases characterised by extracellular deposition of amyloid fibrils
26
What are the two main subtypes of amyloidosis?
Type AA: serum Amyloid A protein
-non-familial secondary amyloidosis: inflammatory polyarthropathies account for 60% of cases
Type AL: immunoglobulin light chain amyloidosis (primary amyloidosis)
27
Which are the main 2 organs affected by amyloidosis?
Kidneys
| Heart
28
What is the epidemiology of amyloidosis?
In the UK, the age-adjusted incidence is between 5.1 and 12.8 per 1 million per year, with around 60 new cases annually- RARE
29
What are the presenting symptoms of amyloidosis?
```
PMH of inflammatory conditions (RF)
Chronic infections (RF)
Positive FH (RF)
Fatigue
Weight loss
Dyspnoea on exertion
```
30
What are the signs of amyloidosis on physical examination?
Jugular venous distension- high right-sided filling pressure
Lower extremity oedema (nephrotic syndrome)
Macroglossia- most specific finding for AL
Diffuse muscular weakness
Shoulder pad sign- psudeohypertrophy of amyloid
31
What are the appropriate investigations for amyloidosis?
1st line:
Serum/ urine immunofixation- presence of monoclonal protein
Immunoglobulin free light chain assay- diagnosing AL
Bone marrow biopsy- clonal plasma cells
Others:
Tissue biopsy, ECG (for conduction abnormalities)
32
What is bladder cancer?
Over 90% of cancers of the urinary bladder are urothelial carcinoma (previously termed transitional cell carcinoma)
33
What is associated with bladder cancer?
```
Smoking*
Aromatic amines (rubber industry)
Chronic cystitis
Schistosomiasis (increases risk of squamous cell carcinoma)
Pelvic irradiation
```
34
What is the aetiology of bladder cancer?
Smoking is the most important causative factor in bladder cancer, increasing the risk two- to fourfold
People with Type 2 DM
Chronic inflammation, Schistosoma infection, and chronic indwelling catheters increase the risk
35
What is the epidemiology of bladder cancer?
Bladder cancer ranks ninth in worldwide cancer incidence. >90% are transitional cell carcinomas (TCCS) in the UK
M:F is 5:2
36
What are the presenting symptoms of bladder cancer?
Painless haematuria
Recurrent UTIs
Dysuria: associated with aggressive bladder cancer
Voiding irritability
37
What are the appropriate investigations for bladder cancer?
Cystoscopy with biopsy is diagnostic* (camera imaging)
Urinalysis: haematuria, microscopy/cytology (cancers may cause sterile pyuria)
Renal and bladder ultrasound: bladder tumours and/or upper tract obstruction may be seen
CT urogram is both diagnostic and provides staging.
Bimanual examination under anaesthetic helps assess spread
MRI or lymphangiography may show involved pelvic nodes
Bloods: FBC (may be mildly anaemic), Alk Phos (may be elevated)
38
What is Chronic Kidney Disease (CKD)?
Defined by either a pathological abnormality of the kidney, such as haematuria and/or proteinuria, or a reduction in the glomerular filtration rate to <60 mL/min/1.73 m² for ≥3 months' duration
(also known as chronic renal failure)
39
What is the aetiology of CKD?
The most common cause in the adult population is diabetes with hypertension as second
- Vascular disease: Hypertension, renal artery atheroma, vasculitis
- Glomerular disease: Glomerulonephritis, diabetes, amyloid, SLE
- Tubulointerstitial disease: Pyelonephritis/interstitial nephritis, nephrocalcinosis, tuberculosis
- Obstruction and others: Myeloma, HIV nephropathy, scleroderma, gout, renal tumour, inborn errors of metabolism (e.g. Fabrys disease)
- Congenital/inherited: Polycystic kidney disease, Alports syndrome, congenital hypoplasia
40
What is the epidemiology of CKD?
Common condition -often unrecognised until the most advanced stages
11% of the adult population worldwide has CKD
The incidence is rising and is thought to be due to an ageing population- a higher incidence of diseases such as diabetes and hypertension
41
What are the presenting symptoms of CKD?
```
Anorexia
Nausea
Malaise
Pruritus (itchiness)
Later: diarrhoea, drowsiness, convulsions, coma
(Symptoms of the cause)
```
42
What are the signs of CKD on physical examination?
```
Systemic:
-Kussmauls breathing: deep, labored breathing (acidosis)
-Signs of anaemia
-Oedema
-Pigmentation
-Scratch marks
Hands:
-Leuconychia (hypoalbuminaemia)
Signs of complications (e.g. neuropathy, renal bone disease)
```
43
What are the appropriate investigations for CKD?
Serum creatinine: determine GFR: elevated: >97 micromol/L (>1.1mg/dL) in men; >105 micromol/L (>1.2 mg/dL) in women
Urinalysis: Haematuria and/or proteinuria, microalbuminuria (30 to 300 mg/day)
Renal Ultrasound: small kidney size (kidney atrophy), presence of obstruction/hydronephrosis, kidney stones
Renal Biopsy: determine underlying pathological diagnosis
Imaging: Signs of osteomalacia and hyperparathyroidism. CXR may show pericardial effusion or pulmonary oedema
Bloods:
-FBC (low Hb: normochromic, normocytic)
-U&E (low urea and creatinine)
-eGFR (can be derived from creatinine and age using the MDRD calculator)
-LowCa2+ , high phosphate, AlkPhos, PTH
44
What is a common complication of CKD?
Renal hyperparathyroidism-elevated parathyroid hormone levels secondary to derangements in the homeostasis of calcium, phosphate, and vitamin D
45
What is Epididymitis and Orchitis?
Epididymitis is characterized by acute unilateral scrotal pain and swelling of less than 6 weeks' duration.
The pain usually begins at the epididymis and can spread to the entire testicle (epididymo-orchitis)
46
What is the aetiology of Epididymitis and Orchitis?
- Among sexually active men of all ages, STI pathogens including Chlamydia trachomatis and Neisseria gonorrhoeaeare common causes of epididymitis
- In older men (>35 years), infection may be due to non-sexually transmitted infection with common uropathogens, such as Escherichia coli and Enterococcus faecalis
47
What is the epidemiology of Epididymitis and Orchitis?
Epididymitis is the most common cause of scrotal pain in adults with an incidence of 25–65 cases per 10,000 adult males per year
Over half of men and boys with epididymitis also have orchitis.
-Isolated orchitis is rare: the commonest cause is mumps infection, although it can also be caused by other viral infections
48
What are the presenting symptoms of Epididymitis and Orchitis?
Gradual onset (unlike testicular torsion)
Unilateral scrotal pain and swelling
Other symptoms: fever, dysuria
49
What are the signs of Epididymitis and Orchitis on physical examination?
Diffuse enlargement of the testis
Erythema of the scrotal skin
Swelling for < 6 weeks: otherwise indicates chronic inflammation
50
What are the appropriate investigations for Epididymitis and Orchitis?
*first catch urine sample
Urethral swab: highly sensitive and specific for documenting urethritis and the presence or absence of gonococcal infection (look for urethral discharge)
Urine dipstick test: positive leukocyte esterase test (urethritis and lower urinary tract infection)
Urine microscopy: WBC
Urine culture: isolate causative organism
Colour duplex ultrasound: done in patients with signs suggestive of abscess formation or possible testicular torsion and infarction; epididymis is enlarged and hyperaemic (increased blood flow)
Consider STI screen
51
What is the management for Epididymitis and Orchitis?
If <35yrs;
-Doxycycline 100mg/12h (covers chlamydia; treat sexual partners)
-If gonorrhoea suspected add ceftriaxone 500mg IM stat. If >35yrs (mostly non-STI) associated UTI is common:
-Ciprofloxacin 500mg/12h or ofloxacin 200mg/12h
*Antibiotics should be used for 2–4wks
Also: analgesia, scrotal support, drainage of any abscess.
52
What are the complications of Epididymitis and Orchitis?
```
(usually of chronic disease, more commonly associated with uropathogen enteric organisms than sexually transmitted organisms) include:
Chronic pain
Reactive hydrocele
Abscess formation
Infarction of the testicle
Testicular atrophy
Reduced fertility
```
53
What is the prognosis of Epididymitis and Orchitis?
In men with infectious acute epididymitis, symptoms usually resolve rapidly following the initiation of appropriate antibiotic therapy
RARE CASES: particularly in STIs-epididymal obstruction/testicular atrophy and subsequent infertility problems
54
What is glomerulonephritis?
Denotes glomerular injury and applies to a group of diseases that are generally characterised by inflammatory changes in the glomerular capillaries and the glomerular basement membrane (GBM)
55
What is the aetiology of glomerulonephritis?
There are many different types of glomerulonephritis with differing aetiologies. Some types of glomerulonephritis are ascribed to deposition of antigen–antibody immune complexes in the glomeruli that lead to inflammation and activation of complement and coagulation cascades. It is commonly idiopathic but there are other causes
56
What are some of the causes of glomerulonephritis?
- Infections (group A beta-haemolytic Streptococcus, respiratory and gastrointestinal infections, hepatitis B and C, endocarditis, HIV, schistosomiasis, malaria, and leprosy)
- Systemic inflammatory conditions such as vasculitides (SLE, rheumatoid arthritis, granulomatosis polyangiitis, microscopic polyangiitis and scleroderma)
- Drugs (penicillamine, gold sodium thiomalate, NSAIDS)
- Metabolic disorders (DM, hypertension, and thyroiditis)
- Malignancy (lung and colorectal cancer, melanoma, and Hodgkin's lymphoma)
- Hereditary disorders (Alport's syndrome, thin basement membrane disease and hereditary complement protein disorders)
- Deposition diseases (amyloidosis)
57
What is the epidemiology of glomerulonephritis?
Makes up to 25% of cases of chronic renal failure
58
What is the epidemiology of glomerulonephritis?
Makes up to 25% of cases of chronic renal failure
59
What are the presenting symptoms of glomerulonephritis?
```
Haematuria
Subcutaneous oedema
Polyuria or oliguria
History of recent infection
Others: anorexia, malaise, weight loss, fever, arthralgia, haemoptysis, skin rash (vasculitic aetiology-Palpable purpura)
```
60
What are the signs of glomerulonephritis on physical examination?
Hypertension
Proteinuria (<3 g/24 h);
Haematuria (microscopic or macroscopic, especially IgA nephropathy)
Nephrotic syndrome -proteinuria
Nephritic syndrome (haematuria, proteinuria, subcutaneous oedema, oliguria, hypertension, uraemia);
61
What are the appropriate investigations for glomerulonephritis?
Urinalysis: haematuria, proteinuria, dysmorphic RBCs, leukocytes, and RBC casts, 24-h collection: creatinine clearance, protein
Metabolic profile: normal or renal failure, elevated liver enzymes, hypoalbuminaemia, elevated creatinine
Bloods: FBC (anaemia), U&E, lipid profile (hyperlipidaemia), GFR, ESR/CRP (elevated), complement levels, anti-neutrophil antibody
Imaging: Renal tract ultrasound (small kidneys)
Renal biopsy: Light microscopy, electron microscopy, immunofluorescence microscopy (pattern of cellular proliferation)
Investigations for associated infections: e.g. hepatitis B, hepatitis C or HIV serology
62
What is a hydrocele?
A collection of serous fluid between the parietal and visceral layers of the membrane (tunica vaginalis) that surrounds the testis, or along the spermatic cord
63
What is the aetiology of a hydrocele?
Primary (associated with a patent processus vaginalis, which typically resolves during the 1st year of life) or secondary to testis tumour/trauma/infection/torsion/varicocele operation/ epididymitis
*Can occur in females but is RARE
64
What is the epidemiology of hydrocele?
Hydroceles are more prevalent in premature infants and in infants whose testes descend relatively late
65
What are the presenting symptoms of a hydrocele?
Scrotal mass- likely to be soft if the communication is large or tense if it is small
Enlargement of the scrotal mass following activity: increasing intra-abdominal pressure makes the peritoneal fluid flow into the scrotal sac- the mass increases in size with activities such as coughing, straining, crying, or raising the arms
66
What are the signs of a hydrocele on physical examination?
Transillumination: Because of the fluid, most hydroceles are easily transilluminated when a focused beam of light is shone on the scrotum
67
What are the appropriate investigations for a hydrocele?
Usually none needed: clinical diagnosis based on features
Ultrasound:
-Can be used in the case of unable to palpate the testis/ underlying pathology/ in rare female cases
68
What is Nephrotic Syndrome?
Characterized by proteinuria (>3 g/24 h), hypoalbuminaemia (<30 g/L), peripheral oedema and hypercholesterolaemia (plus thrombotic disease)
69
What is the aetiology of Nephrotic Syndrome?
```
Commonest cause is minimal change glomerulonephritis in children, but all forms of glomerulonephritis can cause nephrotic syndrome
Other causes:
Diabetes mellitus
Sickle cell disease
Amyloidosis
Malignancies (lung and GI adenocarcinomas)
Drugs (NSAIDs)
Alports syndrome
HIV infection
```
70
What is the epidemiology of Nephrotic Syndrome?
Most common cause in children: minimal change glomerulonephritis (usually seen in boys <5 years, rare in black populations)
Most common causes in adults: Diabetes mellitus, membranous glomerulonephritis
71
What are the presenting symptoms of Nephrotic Syndrome?
FH of atopy in those with minimal change glomerulonephritis
FH of renal disease
Swelling (oedema) of face, abdomen, limbs, genitalia
Symptoms of the underlying cause (e.g. SLE)
Symptoms of complications (e.g. renal vein thrombosis: loin pain, haematuria)
72
What are the signs of Nephrotic Syndrome on physical examination?
Oedema: Periorbital, peripheral, genital
Ascites: Fluid thrill, shifting dullness
73
What are the appropriate investigations for Nephrotic Syndrome?
Blood: FBC, U&Es, LFT (low albumin), ESR/CRP, glucose, lipid profile (secondary hyperlipidaemia), immunoglobulins, complement (C3, C4)
Urine: Urinalysis (protein, blood), CMS, 24-h collection (to calculate creatinine clearance and 24-h protein excretion)
Renal ultrasound: Excludes other renal diseases that may cause proteinuria, e.g. reflux nephropathy
Renal biopsy: In all adults and in children who have unusual features or do not respond to steroids
Other imaging: Doppler ultrasound, renal angiogram, CT or MRI are options if renal vein thrombosis is suspected
Test for underlying cause:
-SLE: ANA
-Vasculitides
-Blood films/cultures
-Goodpastures syndrome: Anti-glomerular basement membrane antibodies
74
What is Polycystic Kidney Disease?
Autosomal dominant inherited disorder characterized by the development of multiple renal cysts that gradually expand and replace normal kidney substance, variably associated with extrarenal (liver and cardiovascular) abnormalities
75
What are the two types of Polycystic Kidney Disease?
Autosomal-dominant PKD (ADPKD)
| Autosomal-recessive PKD (ARPKD)
76
What is the aetiology of Polycystic Kidney Disease?
85% are mutations in PKD1 (polycystin-1) on chromosome 16, multidomain protein involved in cell–cell and cell-matrix interactions
15% are mutations in PKD2 (polycystin-2) on chromosome 4, a Ca2+ permeable cation channel
Pathological process: proliferative/hyperplastic abnormality of the tubular epithelium.
In early stages: cysts are connected to the tubules from which they arise and the fluid content is glomerular filtrate
When cyst diameter >2 mm, most detach from the patent tubule and the fluid content is derived from secretions of the lining epithelium
With time, cysts enlarge and cause progressive damage to adjacent functioning nephrons
77
What is the epidemiology of Polycystic Kidney Disease?
Most commonly inherited kidney disorder affecting 1 in 800
Responsible for nearly 10% of end-stage renal failure in adults
*ARPKD is far less common
Usually present at 30–40 years
20% of patients have no FH
78
What are the presenting symptoms of Polycystic Kidney Disease?
May be asymptomatic
Abdominal/flank pain as a result of cyst enlargement/bleeding, stone, blood clot migration, infection.
Haematuria
UTI symptoms: dysuria, urgency, suprapubic pain, fever
*Associated with intracranial berry aneurysms and may present with subarachnoid haemorrhage: sudden onset headache
79
What are the signs of Polycystic Kidney Disease on physical examination?
Abdominal distension
Enlarged cystic kidneys and liver (hepatomegaly)- palpable on examination
Hypertension
*Signs of chronic renal failure at late stage
*Signs of associated aortic aneurysm or aortic valve disease: cardiac murmur- mitral regurgitation, aortic regurgitation
80
What are the appropriate investigations for Polycystic Kidney Disease?
Renal ultrasound or CT of abdomen/pelvis imaging: Multiple cysts observed bilaterally in enlarged kidneys, sensitivity of detection poor for those <20 years. Liver cysts may also be seen.
*Diagnosis confirmed when there is family history and patient meets result criteria:
<30 years of age: at least 2 unilateral or bilateral cysts
30 to 59 years of age: 2 cysts in each kidney
>60 years of age: 4 cysts in each kidney
81
What is prostate cancer?
A malignant tumour of glandular origin, situated in the prostate
82
What is the aetiology of prostate cancer?
Exact aetiology is unknown. Some factors are:
- High fat diet may increase the risk
- Genetic factors: FH (particularly in Black ethnicity)
83
What is the epidemiology of prostate cancer?
Most common cancer in Men in the UK
| Most commonly seen in elderly men (median age 66 years)
84
What are the presenting symptoms of prostate cancer?
Usually asymptomatic until the tumour is large enough to put pressure on the urethra:
- Nocturia
- Increased urinary frequency
- Urinary hesitancy
- Dysuria
- Haematuria
- Weight loss/anorexia/ lethargy
* These are all seen in later stages of disease (or in benign prostatic hyperplasia)
85
What are the signs of prostate cancer on physical examination?
Digital rectal examination: Asymmetrical, irregular/ nodular prostate
86
What are the appropriate investigations for prostate cancer?
Serum prostate specific antigen (PSA): elevated levels >4 micrograms/L (>4 nanograms/mL)
Bloods: FBC, LFTs, testosterone (mostly normal)
Prostate biopsy: Transrectal ultrasound (TRUS)-guided needle biopsy detect malignant cells and grading
Imaging:
-Bone scan: bone metastases
-Plain x-rays: lytic or blastic lesions
-Pelvic CT scan: enlarged prostate and/or enlarged pelvic lymph nodes
-Pelvic MRI (later stages in the disease)
87
What is renal artery stenosis?
Stenosis (narrowing) of the renal artery
88
What is the aetiology of renal artery stenosis?
Main causes:
- Atherosclerosis (older patient): Widespread aortic disease involving the renal artery ostia (opening of vessel)
- Fibromuscular dysplasia (younger patient): Fibromuscular dysplasia is of unknown aetiology but may be associated with collagen disorders, neurofibromatosis and Takayasus disease. This may be associated with micro-aneurysms in the mid and distal renal arteries (resembling string of beads on angiography)
89
What is the epidemiology of renal artery stenosis?
Atherosclerotic RAS accounts for 90% of all RAS and RAS has a prevalence of 0.2% to 5% in all hypertensive patients
Fibromuscular dysplasia occurs mainly in women with hypertension at <45 years
90
What are the presenting symptoms of renal artery stenosis?
PMH of hypertension in <50 years
Hypertension refractory to treatment
Hx of accelerated, malignant or resistant hypertension and renal deterioration on starting ACE inhibitor
PMH of flash pulmonary oedema (sudden or unexplained)
91
What are the signs of renal artery stenosis on physical examination?
Hypertension
Signs of renal failure in advanced bilateral disease
An abdominal bruit may be heard over the stenosed artery
92
What are the appropriate investigations for renal artery stenosis?
Bloods:
-Serum creatinine (normal or elevated)
-Serum potassium (normal or low)
-Aldosterone to renin ration: excludes primary aldosteronism as cause of HTN and hypokalaemia or low-normal potassium (<20)
Urinalysis and sediment evaluation: exclude other causes
Imaging:
Duplex ultrasound (technically difficult if obese): ultrasound measurement of kidney size (>50% reduction in vessel diameter)
CT angiography or MRA: Often used now; risk of contrast nephrotoxicity (>50% reduction in vessel diameter)
**Digital subtraction angiography: Gold standard assessment (>50% reduction in vessel diameter)
Renal scintigraphy
93
What is Renal Cell Carcinoma?
Renal malignancy arising from the renal parenchyma/cortex, and accounts for about 85% of renal cancers
94
What are the risk factors of Renal Cell Carcinoma?
```
Smoking is the most well-established RF
Obesity
Hypertension
Positive FH of RCC
Increased age (55-84 years)
Renal transplantation and dialysis
```
95
What is the epidemiology of Renal Cell Carcinoma?
Accounts for 90% of renal cancers; mean age 55yrs
M:F≈2:1
15% of haemodialysis patients develop RCC
96
What are the presenting symptoms of Renal Cell Carcinoma?
Often asymptomatic- 50% found incidentally
Classic triad*:
-Flank/loin pain
-Haematuria
-Palpable abdominal mass
*classic presentation occurs in <10% of patients and suggests locally advanced disease
Others:
Non-specific systemic: fever, anorexia, malaise, weight loss, sweats, pallor, cachexia, myoneuropathy (muscle weakness)
97
What are the signs of Renal Cell Carcinoma on physical examination?
Hypertension (increased renin secretion)
Varicocele: Rare, invasion of left renal vein compresses left testicular vein -spread may be direct (renal vein), via lymph, or haematogenous (bone, liver, lung)
25% of patients have metastases at presentation
98
What are the appropriate investigations for Renal Cell Carcinoma?
Bloods:
-FBC (polycythaemia from erythropoietin secretion)
-Lactate dehydrogenase (elevated in advanced RCC)
-Serum creatinine (U&E): indicative of chronic renal insufficiency if elevated with reduced creatinine clearance
-Calcium: advanced RCC: >2.5 mmol/L (>10 mg/dL)
-ALP (bony mets?)
Urine: haematuria and/or proteinuria, RBC sediments; cytology
Imaging:
-US: abnormal renal cyst/mass, lymphadenopathy, metastatic lesions
-CT/MRI: renal mass, regional lymphadenopathy, and/or visceral/bone metastases
-CXR: ‘cannon ball’ pulmonary metastases
99
What is Testicular cancer?
The most common malignancy in young adult men (15 to 44 years of age), and highly curable when diagnosed early
100
What is the aetiology of Testicular cancer?
All germ cell tumours are believed to start developing during fetal development and to progress through a non-invasive stage called intratubular germ cell neoplasia unclassified (carcinoma in situ).
101
What are the different types of Testicular cancer?
1. Seminoma 55% (30–65yrs)
2. Non-seminomatous germ cell tumour, 33% (previously teratoma; 20–30yrs)
3. Mixed germ cell tumour
4. Lymphoma- most common in men > 50 (9-12%)
* *Around 90–95% of testicular tumours are germ cell tumours, mainly teratomas and seminomas
102
What are the risk factors for Testicular cancer?
- Cryptorchidism (undescended testis): relative risk of 2 to 17 times for malignancy, highest risk in abdominal and bilateral undescended testes. Seminoma (predominant type of tumour)
- Gonadal dysgenesis: changes in the gonadotrophin feedback regulation
- FH of testicular cancer
- PMH of testicular cancer: risk of developing a second primary cancer in the contralateral testis
- Testicular atrophy: Can be secondary to trauma, hormones, and viral orchitis (mainly at a younger age)
- HIV infection
- White ethnicity, aged 25-35 years
103
What is the epidemiology of Testicular cancer?
Testicular cancer accounts for 1% of all cancers, and less than 1% of all cancer death in males
In the UK 1,400 men are diagnosed with testicular cancer every year, with the highest incidence in those aged 25–35 years
White men have the highest incidence, compared with African and Asian men
104
What are the presenting symptoms of Testicular cancer?
Testicular mass (usually painless (>85%), 10% present with acute pain)
Extratesticular manifestations: (5-10%) at the time of presentation. These include:
-Bone pain (skeletal metastasis)
-Lower extremity swelling (venous occlusion)
-Supraclavicular lymph nodes
-Symptoms and/or signs of hyperthyroidism
-Gynaecomastia
105
What are the signs of Testicular cancer on physical examination?
Testicular mass: About 55% of cases occur on the right side. In up to 2% of cases, testicular cancer is bilateral
Extratesticular manifestations:
-Bone pain (skeletal metastasis)
-Lower extremity swelling (venous occlusion)
-Supraclavicular lymph nodes
-Symptoms and/or signs of hyperthyroidism
-Gynaecomastia
106
What are the appropriate investigations for Testicular cancer?
*Principal test (sensitivity 100%): Ultrasound of testis: testicular mass
Bloods (tumour markers):
-beta human chorionic gonadotrophin (B-hcg): >0.7 IU/L
-alpha- fetoprotein (AFP): >25 microgram/L
-lactate dehydrogenase (LDH): >25 U/L
Imaging:
CT abdomen and pelvis: enlarged retroperitoneal lymph nodes
MRI: staging tool
CXR: mediastinal and lung mass suggestive of metastasis
Excision biopsy
107
What is a Transurethral resection of the prostate (TURP)?
Surgical procedure used in the treatment of an enlarged prostate (benign prostatic hyperplasia) to relive pressure on the urethra by removing parts of the prostate tissue (gland) and improve the urinary symptoms
108
What are the indications for a Transurethral resection of the prostate (TURP)?
Most common type of surgery for treating an enlarged prostate:
- Benign prostatic enlargement (BPE)
- Benign prostatic hyperplasia (BPH)
109
What are the possible complications of a Transurethral resection of the prostate (TURP)?
Retrograde ejaculation:most common long-term complication of TURP and can occur in as many as 90% of cases (ejaculate flows into your bladder)
Degree of urinary incontinence
Erectile dysfunction (10%)
Narrowing of the urethra (urethral strictures) is estimated to develop in up to 4% of cases
Others:
Bleeding- 3% need to have a blood transfusion
Urinary retention- catheter
Prostate becoming enlarged again- 10% will need another operation within 4-10 years
UTI (5%) after the surgery
110
What is a urinary catheterisation?
A flexible tube used to empty the bladder and collect urine in a drainage bag
111
What are the indications for urinary catheterisation?
When people have difficulty urinating naturally. It can also be used to empty the bladder before or after surgery and to help perform certain tests
Obstruction in the urethra e.g. scarring or prostate enlargement
Bladder weakness or nerve damage that affects your ability to urinate
Drain bladder during childbirth- epidural anaesthetic
Drain bladder before, during or after some types of surgery
Deliver medicine directly into the bladder, such as during chemotherapy for bladder cancer
A last resort treatment for urinary incontinence when other types of treatment have been unsuccessful
112
What are the possible complications for a urinary catheterisation?
Main complications are UTIs (treated with antibiotics)
| Others: bladder spasms, leakages, blockages, and damage to the urethra
113
What is a urinary tract infection (UTI)?
An inflammatory reaction of the urinary tract epithelium in response to pathogenic micro-organisms, most commonly bacteria
114
What is the aetiology of a UTI?
UTIs result from pathogenic organisms gaining access to the urinary tract and not being effectively eliminated
The bacteria ascend the urethra and generally have an intestinal origin; therefore, Escherichia coli causes most UTIs in men and women
115
What are the classifications of UTIs?
Uncomplicated: normal renal tract structure and function
Complicated: structural/functional abnormality of genitourinary tract, eg obstruction, catheter, stones, neurogenic bladder, renal transplant
116
What are the risk factors for a UTI?
1. Increased bacterial inoculation:
- Sexual activity
- Urinary incontinence
- Faecal incontinence
- Constipation
2. Increased binding of uropathogenic bacteria:
- Spermicide use
- Reduced oestrogen
- Menopause
3. Reduced urine flow:
- Dehydration
- Obstructed urinary tract
4. Increased bacterial growth:
- Diabetes Mellitus
- Immunosuppression
- Obstruction
- Stones
- Catheter
- Renal tract malformation
- Pregnancy
117
What is the epidemiology of UTIs?
All patient-care settings identify UTI as the most common infection
The ratio of UTI occurrence between institutionalised women and men is almost equal (2 to 3:1), unlike the ratio for younger women and men (25:1)
118
What are the presenting symptoms of a UTI?
Cystitis: Frequency, dysuria, urgency, suprapubic pain, polyuria, haematuria.
Acute pyelonephritis: Fever, rigor, vomiting, loin pain/tenderness, costovertebral pain, associated cystitis symptoms, septic shock
Prostatitis:
-Pain: perineum, rectum, scrotum, penis, bladder, lower back.
Fever, malaise, nausea, urinary symptoms, swollen or tender prostate on PR*
119
What are the types of lower UTIs?
Bladder (cystitis)
| Prostate (prostatitis)
120
What are the types of upper UTIs?
Pyelonephritis = infection of kidney/renal pelvis
121
What are the signs of a UTI on physical examination?
Fever
Abdominal or loin tenderness
Check for a distended bladder, enlarged (tender) prostate
*If vaginal discharge, consider Pelvic inflammatory disease
122
What are the appropriate investigations for a UTI?
Dipstick urinalysis: positive leukocyte esterase and/or nitrite (avoid using in pregnant women)
*(MSU) Urine culture and microscopy: leukocytes and/or bacteria (≥10^2 CFU/mL)- Use in pregnant women, men, children
Bloods: (if systemically unwell) FBC, U&E, CRP, and blood culture (positive in only 10–25% of pyelonephritis)
Imaging:
-Consider USS (rules out obstruction) and referral to urology for assessment in men with upper UTI; failure to respond to treatment; recurrent UTI (>2/year); pyelonephritis; persistent haematuria
-CT renal tract: perirenal abscess, urinary calculi, or tumours
-CT Kidneys, Ureter and Bladder: urinary tract stone, abscess
*consider urogram for those who have voiding dysfunction without a clearly identifiable cause such as BPH or failure to treatment
123
What is the overall management of a UTI?
The goal of treatment: eradication of bacteria through antibiotics
There are different guidelines for the different populations that can be affected by UTIs
124
What is the management of a UTI in a non-pregnant woman?
If 3 or more symptoms (or 1 severe) of cystitis, and no vaginal discharge: treat empirically with 3-day course of trimethoprim, or nitrofurantoin (if eGFR >30)
- If first-line empirical treatment fails, culture urine and treat according to antibiotic sensitivity.
* In upper UTI, take a urine culture and treat initially with a broad-spectrum antibiotic according to local guidelines/sensitivities, eg co-amoxiclav.
125
What is the management of a UTI in a pregnant woman?
*Get expert help
UTI in pregnancy is associated with preterm delivery and intrauterine growth restriction
Asymptomatic bacteriuria should be confirmed on a second sample
Treat with an antibiotic- local guidance advice for antibiotic choice (avoid ciprofloxacin, trimethoprim in 1st trimester, nitrofurantoin in 3rd trimester)
Confirm eradication.
126
What is the management of a UTI in a man?
Treat lower UTI with a 7-day course of trimethoprim or nitrofurantoin (if eGFR >30)
- If symptoms suggest prostatitis (pain in pelvis, genitals, lower back, buttocks) consider a longer (4-week) course of a fluoroquinolone (eg ciprofloxacin) due to ability to penetrate prostatic fluid
- If upper or recurrent UTI, refer for urological investigation
127
What is the management of a UTI in a patient with a catheter?
All catheterized patients are bacteriuric
Send MSU only if symptomatic (symptoms of UTI may be non-specific/atypical)
Possible symptoms:
Fever, flank/ suprapubic pain, change in voiding pattern, vomiting, confusion, sepsis
-Change long-term catheter before starting an antibiotic.
-Where possible use a narrow-spectrum antibiotic according to culture sensitivity.
128
What are the complications of UTIs?
Prostatitis
Pyelonephritis
*Renal function impairment: RF include prostatitis, obstruction, the presence of stones, and the presence of indwelling catheters
*Sepsis
129
What is the prognosis for a UTI?
In the absence of a complicated UTI, antibiotic therapy is more effective and results in fewer failures
Younger patients have a better prognosis
Older patients often have a complicated UTI
130
What is a Urinary tract calculi?
The presence of crystalline stones (calculi) within the urinary system (kidneys and ureter)
131
What is the aetiology of Urinary tract calculi?
Renal stones are crystalline mineral depositions that form from microscopic crystals in the loop of Henle, distal tubules, or the collecting duct- Ureteric stones almost always originate in the kidney but then pass down into the ureter
85% are composed of calcium, daily calcium oxalate
10% are uric acid
2% are cystine
132
What is the epidemiology of Urinary tract calculi?
The lifetime prevalence of nephrolithiasis (stones in the urinary system) is estimated to be between 5% and 12% with men more affected than women
Highest prevalence is found in white ethnicity
133
What are the presenting symptoms of Urinary tract calculi?
```
Actue severe flank pain
Nausea and vomiting
Urinary frequency and urgency
Haematuria
Groin pain
Possible: rigors and fever
May have symptoms of a UTI: dysuria
```
134
What are the signs of Urinary tract calculi on physical examination?
Patients may in be extreme discomfort
Tachycardia
Hypotension
Abdomen tender on palpation on the affected side
Lack of peritoneal signs (guarding, rebound, rigidity)
135
What are the appropriate investigations for Urinary tract calculi?
Urinalysis:
-May be normal
-Dipstick positive for leukocytes, nitrates, blood
-Microscopic analysis positive for WBCs, RBCs, or bacteria
Bloods: FBC, U&Es, creatinine
Stone analysis
Imaging:
-Non-contrast helical CT: calcification seen in renal collecting system or ureter; hydronephrosis, perinephric stranding (indicative of inflammation or infection)
-Plain KUB x-ray: calcification seen within urinary tract
-Renal ultrasound: calcification seen within urinary tract, hydronephrosis
Others:
- IV pyelogram (old)
- 24 hour urine collection (exclude metabolic causes)
- Spot urine for cysteine: cystinuria
136
What is the management for Urinary tract calculi?
Hydration and analgesia/anti-emetics
Facilitate calculus passage e.g. with alpha receptor blockers such as tamsulosin (<10mm)
For large calculi (>10mm)/persistent/infection causing calculi: complete removal using endoscopic techniques e.g. Extracorporeal shock wave lithotripsy
*dietary modification
137
What are the complications/prognosis of Urinary tract calculi?
Recurrent calculi, complications of surgery (bleeding, haematoma, infection)
Nephrolithiasis is a lifelong disease process
138
What are the risk factors for Urinary tract calculi?
```
Diet:
-High protein intake- intake of purine (meat, fish, poultry)
-High salt intake
Dehydration
Obesity
FH
```
139
What is a Varicocele?
The abnormal dilation of the internal spermatic veins and pampiniform plexus that drain blood from the testis
140
What is the aetiology of Varicocele?
Anatomical features, namely:
-increased hydrostatic pressure in the left renal vein
-incompetent or congenitally absent valves
are typically implicated as the primary causes of varicocele formation
141
What is the epidemiology of Varicocele?
It has been estimated that between 10% and 15% of men and adolescent boys in the general population have varicocele
Greater incidence of varicocele in first-degree relatives
*Varicoceles appear to be more common in males who are tall and heavy, although with a lower BMI than age-matched controls
142
What are the presenting symptoms of Varicocele?
Are often asymptomatic
Painless scrotal mass
Left sided symptoms (around 90% occur on the left side, and 10% of cases are bilateral)
Small testicle- larger varicoceles are associated with higher incidence of testicular growth arrest
*Infertility: varicoceles are present in around 40% of men with fertility problems
143
What are the signs of Varicocele on physical examination?
Painless scrotal mass- classically described as feeling like a bag of worms
Left sided symptoms
Small testicle
144
What are the appropriate investigations for a Varicocele?
Clinical diagnosis: physical examination is the primary diagnostic test for varicoceles
Scrotal ultrasound with colour flow doppler imaging: presence of varicocele; identification of sub-clinical varicocele
Semen analysis: for infertile men with a varicocele, 2 or 3 semen analyses are recommended
Bloods: serum testosterone (may be low), serum FSH (FSH may be elevated suggesting testicular dysfunction)
CT/MRI abdomen and pelvis: if a varicocele does not diminish in the supine position (or R sided), helps exclude abdominal, pelvic, or retroperitoneal mass
