Renal/Urology Flashcards
1
Q
What level is they kidney found at?
A
T12 and L3
2
Q
Which kidney is slightly lower than the other one?
A
The right kidney
3
Q
What are the 3 layers of the kidney and name a key structure in each of the layers:
A
Renal Cortex: This is Maude up of the glomerulus and the bowman’s capsule
Renal Medulla: Collecting ducts and the loop of Henle
Renal Pelvis: where the urine collects. Contains the collecting ducts. lined with transitional cell epithelium
4
Q
What does the renal artery branch into? (5 branches)
A
Renal Artery
Segmental Artery
Arcuate Arteries
Interlobar Arteries
Interlobular Arteries
Afferent Arterioles
5
Q
What is the basic function of the PCT?
A
Needed to absorb solutes
6
Q
Basic Function of the Loop of Henle?
A
To concentrate the urine
7
Q
What is the purpose of the DCT?
A
To absorb any further water and/or solutes
8
Q
What is the purpose of the collecting ducts?
A
Water reabsorption and acid/base balance.
9
Q
What is the JGA and what does it do?
A
The JGA is an afferent arteriole that responds to low levels of Na+ in the macula densa
If Na+ goes down you get vasodilation of your afferent arterioles and increased glomerular filtration.
10
Q
What are mesangial cells?
A
These are SM cells that surround the arterioles allowing GFR to change in the kidney.
11
Q
What is the charge of the glomerular filtration membrane?
What type of molecules can pass through?
A
The GFM is negatively charged
As such it means that you repel your negatively charged ions like albumin.
It can let small molecules through like potassium creatinine and glucose.
12
Q
When is ADH secreted?
A
When the blood volume is low
Leading to increasing tubular permeability to H2O and causing an increase in blood volume.
13
Q
What two hormones causes there to be an increased reabsorption of of Na+?
A
You have ANP
You also have Aldosterone.
Both work by acting on the ENAC channels. increasing Na+ reabsorption and increasing K+ excretion.
These channels are found in the collecting ducts
14
Q
Where do thiazide like diuretics work>?
A
They work on the DCT
15
Q
What is reabsorbed at the PCT?
A
Sugar
Amino Acids
Bicarbonates
16
Q
Briefly explain the main points of the Renin Angiotensin System:
A
Drop in Blood Pressure/Blood Volume causes the kidney to release Renin
Renin acts on angiotensinogen released by the liver. This causes it to break into angiotensin I
Angiotensin I is the converted by ACE enzyme in the Lungs to create angiotensin II this acts directly on the blood vessels causing vasoconstriction. And causes the adrenal gland to release aldosterone. This increases Na+ reabsorption.
17
Q
Is urinating a parasympathetic or sympathetic process?
A
It is parasympathetic
Storing of urine is sympathetic and relies on Onuf’s nucleus.
18
Q
Renal Stones
What are 3 RF of them?
A
Renal Stones RF include
Dehydration
Cancer/Gout
Medications (diuretics, allopurinol and aspirin)
Trauma (infection) and congenital issues (such as a duplex kidney)
19
Q
Renal Stones
What is the presentation like in a renal stone?
A
Can be asymptomatic
But once symptomatic you generally get loin to groin pain. Pain on urination, Blood in urine, increased frequency of urinating.
Nausea and Vomiting. generally feel unwell
20
Q
Renal Stones
What are the 4 main types of renal stones
A
Calcium oxalate
Calcium phosphate
Uric Acid
Infection induced stones
21
Q
Renal Stones
What are some investigations you would like to do?
What is your GOLD STANDARD investigation?
A
FBC
U+E
Urine Dip and MC+S
Non Contrast CT KUB or an Ultrasound (if pregnant)
22
Q
Renal Stones
State the management of renal stones for varying sizes
A
Small size: possibly can pass on their own. For these patients give analgesia (IV diclofenac) and possibly Nifedipine
Larger stones may need to have ESWL!
23
Q
Acute Kidney Injury
What is defined as AKI?
A
An acute sustained drop in kidney function
Normally seen as a rise in serum urea and creatinine due to a rapid decline in GFR
Generally seen as a rise in creatinine by a 20 point jump
24
Q
AKI
How can you stage/classify the AKI?
A
You use the RIFLE classification.
25
AKI
Who are AKI common in? give a general scenario:
Common in the elderly
Associated with diarrhoea, vomiting and dehydration
26
AKI
Name a couple of pre renal, renal and post renal causes
Common causes: ischaemia, sepsis and nephrotoxins
Pre renal: hypoperfusion, hypovolaemia and renal hypotension. Or rhabdomyosis or NSAID or ACE inhibitor induced.
Renal: glomerulonephritis, haemolytic uraemic syndrome or acute tubular necrosis
Post renal: Urinary tract obstruction via stones, clots or masses
27
AKI
Give two examples of nephrotoxic drugs that can lead to an AKI
NSAIDs
| ACE inhibitors
28
AKI
How does a patient typically present when they have an AKI?
Poor urine output
High urea causes: Confused, Nausea, Vomiting, Seizures and Fatigue
Thirsty
Irregular Heartbeat (hyperkalemia)
29
AKI
How do you diagnose an AKI?
You need to do
Ultrasound
U&Es, serum calcium, phosphate and uric acid
Urine dipstick, microscopy and culture
ECG to exclude Arrhythmias
Renal Biopsy to exclude renal causes
CT-KUB may be indicated
30
AKI
How do you treat a pre renal, renal and post renal AKI?
Pre Renal: get the patient hydrated with IV fluids. Treat any underlying infection
Renal: you need to treat the cause. I.e nephritis give the patient immunosuppressive therapy or prednisolone
Post renal: catheterise, stop nephrotoxic drugs. Is there an option for surgery
31
AKI
How do you treat acidosis in your patient?
How do you treat hyperkalaemia?
You give them sodium bicarbonate
You give them calcium gluconate and insulin
32
Nephritic Syndrome:
What is nephritic syndrome characterised by?
Triad of
- Haematuria
- Proteinuria
- Hypertension/oedema
33
What is the commonest cause of nephritic syndrome?
IgA nephropathy
34
Nephritis
What are 3 causes of nephritis?
Ig A nephropathy
Post strep infection
SLE or ANCA associated vasculitis
Hep B or C
35
Nephritis
How does it present?
It presents via a triad of:
```
Proteinuria
Oedema/ Hypertension
Haematuria
Oliguria
Uraemia (anorexia, lethargy, nausea and decreased kidney function)
```
36
Nephritis:
How is it diagnosed?
You need to do GFR/U&Es and renal US and biopsy
37
Nephritis:
How do you manage the condition?
You need to treat the HTN by giving loop diuretics CCB and salt restriction
You need to treat the cause
38
Nephrotic Syndrome
What is it a triad of?
Hypoalbuminemia
Oedema
Proteinuria
Severe hyperlipidaemia is also common
39
Nephrotic syndrome:
What are 3 common causes of it?
Minimal change syndrome
Membranous nephropathy
Focal Segmental Glomerulosclerosis
40
Nephrotic syndrome
What is the presentation?
Normal / slightly increased BP
Proteinuria
Hypoalbuminaemia
Pitting oedema of the ankles, genitals and the face
Frothy urine
41
How do you diagnose nephrotic syndrome?
You diagnose it through doing routine blood s for albumin, autoantibodies , urine dipstick and then do a
Renal Biopsy! Gold Standard
42
What is the management of nephrotic syndrome?
manage the oedema with furosemide people
Reduce proteinuria with ramipril
Reduce clot reduction with warfarin and simvastatin
For minimal change syndrome give the patient high dose steroids.
43
How do you treat Ig A nephropathy?
You give the patient Ramipril to prevent proteinuria and HTN
You give cyclophosphamide to prevent the autoimmune response.
44
CKD
What is CKD? .
CKD is when there is progressive impairment in renal function (Haematuria and proteinuria) for more than 3 months.
Normally seen as GFR <60 for 3 months or more
45
CKD
What are 3 causes of CKD?
Diabetes
Amyloid
HTN
PKD
Atherosclerosis
46
CKD
How does it present?
Generally assymptomatic to begin with. However, once the urea starts to rise you start getting an increase in symptoms such as:
```
Malaise
Anorexia
Insomnia
Polyuria
Nausea
Vomiting and oedema
```
Long term complications include: anaemia and bone pain, high urea levels can also lead to seizures and paresthesia
HTN and CVS disease can occur as RAAS is not working correctly and HTN ensures.
47
CKD
How can it be diagnosed?
You need to do U&Es, eGRF, urine dipstick, MSU C+S
Important to look at electrolyte levels, PTH, all phosphatase as well
You need to do an US of the kidney will show small kidneys
ECG to see if high K+ levels are contributing to any arrhythmia
48
CKD
How is it managed?
You give
Ramipril (ACE inhibitor) to control BP
Vitamin D and calcium supplements
CVD control via aspirin and statin use
Oedema (give furosemide) and if anaemia (give EPO)
49
CKD
Give the stages of CKD from stage 1 to stage 5.
Stage 1: damage kidney but normal kidney function. GFR >90
Stage 2: mild loss 60-89
Stage 3a: mild to moderate loss 45-59
Stage 3b: moderate to severe loss 30-44
Stage 4: severe loss 15-29
Stage 5: kidney failure: < 15
50
What are the two receptors that control fluid balance in the body?
Where are they found and how do they work?
Osmoreceptors are found in the posterior pituitary and release ADH. This causes vasoconstriction and increased BP
Baroreceptors are found in the aortic arch and carotid sinus. They stimulate ADH release from the posterior pituitary
51
What are 4 indications for dialysis in a patient?
Fluid Overload resulting in pulmonary oedema
High K+ that is resulting in symptoms such as tall tented t waves etc
Symptomatic uraemia
52
What are the 2 types of dialysis?
Haemodialysis
Peritoneal dialysis
53
What are 3 complications of dialysis?
Increased risk of malignancy
Amyloid deposit
Infection
CVS disease
54
ADPKD
When does AD polycystic kidney disease normally manifest its self?
What are some symptoms of PKD?
Normally in the 20s to 30s
Sx: include loin pain, haematuria, renal colic, renal stones, renal mass and HTN.
55
Is EPO preserved in PKD
true or false?
True!
56
ADPKD
What is the management?
BP control Ramipril
Pain relief
Ultimately will need a kidney transplant
57
ARPKD
When does AR PKD normally present?
What other conditions is it associated with?
It presents normally in utero or in infant hood. Worse and more progressive form.
It is also associated with liver involvement through causing congenital hepatic fibrosis
58
Testicular Lumps: diagnose the following
Separate and cystic
Separate and solid
Can’t get over the lump
Testicular and cystic
Testicular and solid
Separate and cystic: epididymal cyst
Separate and solid: varicocele
Can’t get over the lump: inguinoscrotal hernia
Testicular and cystic: hydrocele
Testicular and solid: testicular tumour
59
What is the main function of the testes? How does it do this?
To produce sperm
Seminiferous tubules -> spermatozoa -> rete testes -> efferent tubule -> epididymis
60
What structure is the penis made up of?
Crura is made up of corpus cavernousa
The bulb is made up of corpus spongiosum and is where the urethra runs through
61
Epididymal Cysts:
What is one?
Who is it common in?
How does it present?
How to diagnose/manage?
These are cystic changes that happen in the testicle
It is common in men around there 40s . Tend to be. Well defined. Multiple of them and bilateral
They are tender and swollen lumps
They are diagnosed via US and if needed an aspirate can be taken
management: conservative.
62
Hydrocele
What is one?
Who is it common in?
How does it present?
How to diagnose/manage?
Abnormal fluid collection in the tunica vaginalis.
They can be primary: congenital due to a patent processus vaginalis
Secondary: trauma, malignancy or TB.
Px: normally smooth and non tender. They are not painful.
Diagnosis: US and alpha feto protein/ HCG to exclude tumours
Management: in infancy they resolve on their own. In adults you may want to aspirate.
63
Varicocele
What is one?
Who is it common in?
How does it present?
How to diagnose/manage?
Is when you have abnormal dilation of the testicular veins in teh pampinform plexus. Commonly affecting the left renal vein and left testicle more
Scrotum may feel a bit like a bag of worms and have a heavy/ache feeling.
Diagnosis: colour Doppler ultrasound
Mx: unless pain/infertility you can just leave it.
64
Testicular Torsion:
What testicle is more likely affected?
The left hand side
65
What’s the presentation of testicular torsion?
The person is normally young in age. And you get sudden onset abdominal/testicular pain that is worse on one side. Walking is hard
Likely to have nausea and vomiting.
66
What should you do if you think the patient has testicular torsion>?
Urgent surgical exploration!!
Do orchidectomy and fix the opposite testicle
67
Testicular Tumours;
What age are they common in?
What are two RF:
What is the clinical presentation?
They are common in men aged 15-44
Two RF include: undescended testes and infant hernia
The patient will have a painless testicular lump that may present with a hydrocele. The patient may have testicular or abdominal pain. Likewise if the patient has a cough or back pain the patient is likely to have lung/bone mets
68
Testicular Tumours:
What are some useful diagnostic methods that can be used
Ultrasound biopsy and histology
Alpha Fetoprotein
B-HCG
69
What tumour type in testicular cancer is common in
Children
Adults
Children: non seminomas aka teratomas
Adults: germ cell aka seminomas tumours
70
What are some reasons why PSA would be raised?
An increased BMI
Afro Caribbean heritage
Prostate Cancer
BPH
Perianal trauma or recent ejaculation
71
BPH
What are two tools you can use to measure the impact BPH is having on a patient?
Frequency Volume Chart
IPSS (international prostate symptom score)
72
Acute urinary retention:
What are some causes of this?
How would you diagnose it?
```
BPH
Infection
Alcohol
Constipation
Anticholinergics
```
73
How do you manage acute urinary retention?
Prescribe a catheter
Alpha 1 blockers (Tamsulosin)
If BPH give the patient a 5 alpha reductase inhibitors i.e. finasteride
74
Chronic Urinary Retention:
What are the two types?
What are the 3 main causes?
Low Pressure: detrusor failure
High Pressure: interactive obstructive uropathy
Causes: BPH, pelvic malignancy and Diabetes
75
How does Chronic Urinary Retention presents?
How do you treat it?
It generally presents with overflow incontinence/ day or night wetting
Loss of appetite, constipation and distended abdomen
Treat the cause and Cathertise the patient
76
What are the 3 types of urinary tract obstruction? Give an example for each:
Luminal: stones, blood clot or tumour
Mural: congenital, NM dysfunction or schistosomiasis
Extra mural abdominal or pelvic mass or BPH or prostate cancer
77
On a urinary tract obstruction what investigation would you like to do?
Bloods (U&E, MSU culture and sensitivity)
Ultrasound
78
How would you manage a urinary tract obstruction?
You would give the patient if
Upper tract obstruction: alpha antagonist (Tamsulosin) and a 5 alpha reductase inhibitor (finasteride)
Lower tract obstruction: put a catheter in (good long term = suprapubic catheter). If necessary you may need to do TURP.
79
What are the indications for surgery in a patient with LUTS symptoms?
RUSHES
```
Retention
UTI
Stones
Haematuria
Elevated creatinine
Symptom deterioration
```
80
What layer of the prostate becomes enlarged in BPE/Benign prostatic hyperplasia?
You get an enlargement of the inner transitional layer
81
What layer of the prostate enlarges with prostate cancer?
The layer that enlarges in prostate cancer is your peripheral layer
In BPH you get enlargement of the transitional zone
82
What medication would you give to a patient with BPH?
tamulosin (alpha 1 antagonist)
Finasteride (5 alpha reductase inhibitor)
83
Renal Cell Carcinoma:
What is the typical presentation?
How is it diagnosed?
How is it managed?
You can get loin pain/abdominal mass
Or you can get malaise, weight loss etc
Haematuria is common (microscopic)
Diagnosis is via an US and also byCT
Management: nephew followed by biological chemotherapy like sunitinib
84
Bladder Cancer:
What are the symptoms?
How is it diagnosed?
How is it treated?
Painless haematuria
Recurrent cystitis
LUTS
Diagnosis: cystoscopy and biopsy
Management: surgery and chemotherapy.
85
What region of the prostate is prostate carcinoma seen in?
What is the name given to the staging system used?
It is seen in the peripheral zone.
Gleason’s Scale
86
What is the gold standard investigation for prostate cancer?
The gold standard is trans rectal ultrasound and biopsy.
87
What is the main treatment for prostate cancer?
You can do Androgen deprivation therapy with the LHRH agonist like Goserelin
Alternatively. If you want a rapid decline in sx such as bone pain. Do a radical prostatectomy
88
What is the first line antibiotic treatment to use in a non pregnant lady with UTI
What should you use in a pregnant lady with a UTI first and second trimester?
What should you use in a pregnant lady with a UTI in her 3rd trimester?
Nitrofurantoin
1st and 2nd trimester use Nitrofurantoin
3rd trimester use Trimethoprim
89
What Abx should you use a patient (non pregnant) with pyelonephritis?
Co amoxiclav
90
What should you use in a patient with pyelonephritis and pregnant
Ceflaxin
91
Prostatitis
What is the most common cause in men <35 ?
What is the most common cause in men >35?
Common in under 35 yrs to be STI related generally chlamydia
Over 35s test to be E.coli related
92
Prostatitis
How does acute prostatitis present?
How does chronic prostatitis present
Acute prostatitis presents with fevers, rigours and malaise. LUTS symptoms and pain on ejaculation/pelvic pain
Chronic prostatitis: recurrent UTIs, pelvic pain an acute symptoms for more than 3 months.
93
Prostatitis:
How do you manage the Acute form?
How do you manage Chronic prostatitis?
Acute: give abx such as gentamicin and co amoxicillin
Chronic: tends not to respond well to abx. Instead give alpha blockers (Tamsulosin) and NSAIDs
94
Urethritis:
What is the most common cause?
Chlamydia
Other causes include trichomonas vaginalis and gonorrhoea
95
How does urethritis present?
It presents with pain on seeing
Discharge
Urethral pain
Penile discomfort
Systemic symptoms
96
What antibiotics do you use for chlamydia?
Doxycycline
97
What abx do you use for gonorrhoea?
IM ceftriaxone and doxycycline
98
What are causes of epididymal orchitis in under 35s vs over 35s
What is a pathogen that can also cause it?
Under 35 think: STI related
Over 35 think: KEEPs related
Pathogen associated is MUMPS
99
What is bradytherapy?
This is when you get radioactive seeds placed within the prostate. These produce radiation over time.
100
What do you have to give alongside a LHRH agonist?
LHRH agonist and also an anti-androgen
This prevents tumour flare
Eg. Goserelin
101
Give a comparison of a LHRH agonist vs a LHRH antagonist:
LHRH antagonist work within 24 hrs to castrate the individual. No anti androgen is necessary as no chance of tumour flare.
Eg. Degarelix this is useful for symptomatic metastatic disease as it works with 24 hours.
102
What is the gold standard investigation for renal stones?
Non contrast CT :)
103
What is phimosis?
A non retractible foreskin. Common in boys under the age of 2
Only an issue if it becomes symptomatic through local pain, haematuria or urinary obstruction.
104
Two causes of phimosis?
Congenital
Balanoposthitis (recurrent infection leads to scar tissue formation)
105
How does Phimosis present?
Non retractable foreskin or parents may notice a ballooning structure on urination.
If pathological secondary to balanopsitis. The patient may have painful erections, haematuria, recurrent UTIs, swelling or redness
106
What is the treatment for congenital and pathological phimosis?
Congenital: only treat if it is still there after the age of 2. Likely treatment is circumcision
Pathological phimosis may need abx or steroids
107
What is paraphimosis?
This is a condition where you have a tight prepuce that is retracted an is unable to be replaced when the glans swells.
108
What are some risk factors of paraphimosis?
```
Vigorous sexual activity
Chronic balanopositis (common in DM)
```
109
How does paraphimosis presents?
It presents with pain and oedema around the prepuce band.
Pain on erection
the glans can then become blue/black after necrosis.
Infants can present with irritability
110
How do you treat paraphimosis?
You can do gentle compression with a saline swab
Gentle manual reduction
Surgery
111
how do you treat Balanitis?
Topical steroids and an anti fungal
112
What is fournier’s gangrene?
This is a form of necrotising fasciitis that occurs around the scrotum or the vulva
It involves and deep soft tissue compartment i.e. dermis, S.C. fat or fascia
113
Why is it hard to diagnose fournier’s gangrene?
It is hard to diagnose as its a great mimicker of cellulitis.
Note. The patient will be experiencing pain, tenderness and be systemically unwell out of proportion to if they had cellulitis
114
How long does it roughly take for fournier’s gangrene to develop?
Does it respond to abx?
It roughly takes 1-2 days
It does not respond to antibiotics typically used for cellulitis
115
How do you investigate fournier’s gangrene?
You investigate fournier’s gangrene with X-Rays and also explorative surgery.
116
How do you treat fournier’s gangrene?
You treat it with surgical explorative and debridement
You then use broad spectrum abx
117
What is priapism?
This is when you have an unwanted painful erection of the penis that is not associated with sexual desire lasting more than 4 hours
118
What is a big RF for priapism?
Sickle Cell anaemia
Leukaemia
Viagra
Spinal, perineal or penile trauma
119
What investigations do you organise for priapism?>
You need to do a corporeal blood gas. to determine if it is ischaemic or non ischaemic
Routine bloods, clotting, drug profile and also HB electrophoresis
120
How do you manage priapism?
You manage it through doing corporeal aspiration
Intracavernosal injection of adrenaline
may need surgical management (put a shunt in)
121
What is the pathophysiology of a penile fracture?
A penile fracture happens when you get traumatic rupture of the tunica albuginea and the corpus cavernosa
122
What are the clinical features of a penile fracture:
Forceful thrust to the perineum of the partner followed by a popping sensation with pain, swelling and detumescence (drop from the erection)
The penis will swell and will become discoloured. It will deviate to the opposite side of the lesion.
There will be a immobile firm haematoma s the start (rolling sign) whilst a butterfly sign signifies urethral damage.
123
How do you investigate a penile fracture?
Mostly diagnosed clinically however, you can also do a cavernosography!
124
What is the management of a penile fracture ?
Anti emetic
Analgesia
Surgery
Abstinence from SI for 6-8 weeks
