Renal_Medicine & Surgery

Question 1

Benign prostatic hyperplasia (BPH) - def? Sx? Ix? Mx?

Answer 1

Def: slowly progressive hyperplasia of periurethral (transition) zone of prostate gland –> urinary outflow obstruction

• Common - occuring primarily in elderly men

Sx: lower urinary tract symptoms (FUND HIPS)

Ix: urinalysis (UTI), PSA (cancer) ± US/CT (abdo/pelvis)/cystoscopy

Mx:

• Acute retention = CATHETERISE
• Conservative - watchful waiting
• Medical:
  
  • Alpha-blocker (relax sm muscle around prostatic urethra) e.g. tamsulosin
  • 5-alpha-reductase inhibitor (reduce conversion of testosterone –> dihydrotestosterone - reducing androgenic stimulation of prostate) e.g. finasteride
• Surgical: TURP (transurethral resection of the prostate - shave extra prostate), open prostatectomy
  
  • NOTE: TURP not curative - will continue to grow

Question 2

Urinary tract calculi - def? presentation? Stone types? Ix? Mx? When to ADMIT/what to do if managed @home?

Answer 2

Def: crystal deposition within the urinary tract

Presentation: severe loin to groin pain (ureteric colic - starts around back and moves towards groin)

Stone types:

• Ca oxalate (80%)
• Mg Ammonium Phosphate (struvite) - likely staghorn calculi
  
  • Associated with proteus mirabilis inf
• Urate
• Cysteine

Ix:

• Bedside - urine dip (microscopic haematuria)
• Bloods - U&E (post-renal AKI)
• Imaging - gold standard non-contrast CT KUB (kidneys, ureters, bladder)
  
  • Contrast is excreted by kidneys - looking for bright white light of Ca –> if you give contrast it will mask the finding

Mx:

• Infected & obstructed = pyonephrosis –> URGENT decompression via NEPHROSTOMY (or retrograde w/ JJ stent)
  
  • Opening between kidney & skin w/ nephrostomy bag for external collection
  • Nephro (kidney) stomy (opening)
• <5mm (on CT) - allow spontaneous passing, retain stone for analysis
• >5mm (on CT):
  
  • Ureteroscopic lithotripsy - endoscope into ureter & using mechanical force/laser to destroy stone
    
    • Uretero (through ureter) scopic (camera) Litho (stone) tripsy (crush)
  • Extracorporeal shockwave lithotripsy - external USS to destroy stone
    
    • Extra (outside) corporeal (body) shockwave (USS) Lithtripsy (crushing stone)
  • Percutaneous nephrolithotomy - ONLY if stone in kidney (e.g. staghorn calculi), extract stone through skin in back
    
    • Percutaneous (through skin) Nephro (kidney) lith (stone) otomy (cutting)

When to ADMIT:

• Pain not controlled
• Significantly impaired renal function
• Single kidney
• Pyrexia/sepsis
• Stone >5mm

If managed at home:

• High fluid intake + return if pain worsening/develop temperature
• OPA in 4 weeks with CT-KUB on arrival –> if stone still present need lithotripsy/nephrolithotomy

Question 3

Scrotal masses - ddx?

Answer 3

DDx:

• Testicular torsion - EMERGENCY & TIME-URGENT
  
  • Elevated testis, loss of cremasteric reflex, very tender
  • Tx: bilateral orchidopexy (orchidectomy - if necrotic)
• Can you feel above swelling?
  
  • YES - swelling separate from testis?
    
    • YES - Epididymal cyst OR Varicocele
    • NO - Tender?
      
      • YES - Epididymo-orchitis
      • NO - Hydrocele OR Tumour
  • NO - Inguinal hernia

Question 4

Hydrocele - def? Ix?

Answer 4

Def: collection of fluid in tunica vaginalis

Ix: US, testicular tumour markers (AFP & bHCG - secreted by tumour, LDH - necrosis), urine culture (inf)

Causes: idiopathic, inf, trauma, tumour

Question 5

Varicocele - def? What side is more common? What is it associated with x2? How can I reduce swelling?

Answer 5

Def: distended veins of pampiniform plexus

Key points:

• More common on left (the way left testicular vein drains into left renal vein)
• Assoc w/ infertility, renal cancer
• Swelling may reduce when lying down

Question 6

Testicular cancer - Epidemiology & mets? Ix? Mx?

Answer 6

Epidemiology & mets:

• Mets to para-aortic LNs
• Most common malignancy in males 20-40yrs

Ix:

• Blood testicular tumour markers: alpha-fetoprotein, beta-hCG, LDH (necrosis, others secreted by tumour itself)
• Testicular US –> CT-CAP for staging (would likely do orchidectomy before CT)
• Urine dip (look for infection) –> culture

Mx:

• Orchidectomy – take inguinal approach (scrotal approach risks mets and inguinal is coming out the same way the testicle drops) - only time would not do this first is when respiratory compromise then would do chemo first
• BEP chemotherapy follow-up = very good response typically
• Very good prognosis - good/intermediate prognosis groups have >90% 5-yr survival

Question 7

Bladder cancer - presentation? Ix? Mx?

Answer 7

Most common = transitional cell carcinoma (urothelial)

Presentation:

• Painless visible haematuria (or asymptomatic non-visible haematuria)
• Irrigative LUTS (urgency, suprapubic pain)
• Recurrent UTIs
• Pain, weight loss, lymphoedema

Ix:

• Initial:
  
  • Urine dip (blood, leucocytes)
  • MC&S (use MSU - RBCs & WBCs, no bacterial growth)
  • Bloods - FBC
• Flexible cystoscopy (lower urinary tract) + CT-urogram (upper urinary track if visible haematuria –> if non-visible low-risk use US)
• Dx & staging = Transurethral Bladder Tumour Resection (TURBT) - resects full tumour + histology
  
  • Intravesical therapy:
    
    • Bacillus Calmette-Guerin (BCG) instilled into bladder –> reduces superficial bladder cancer recurrence (causes immune response to remaining tumour cells, same substance as in BCG vaccine)
    • Mitomycin - cytotoxic chemo agent

Mx: 2wk wait urology

• Muscle invasive = cystectomy (young people) or radiotherapy/chemotherapy (older)
• Superficial = surveillance cystoscopies, intravesical chemo
• Mets = systemic therapy

Question 8

AD Polycystic Kidney Disease (PCK)

Presentation? Associations? Screening?

Answer 8

Presentation: HTN, abdo discomfort, blood in urine, FHx of IC haemorrhage

• Cysts in kidneys prod renin –> HTN
• Space occupying masses in abdo (renal/liver cysts)
• Can bleed into cysts –> blood in urine

Associations:

• Hepatic cysts
• Berry aneurysms –> risk of ICH
• Mitral valve prolapse

Family screening - renal USS

Question 9

Testicular torsion - presentation? Tx?

Answer 9

Presentation: sudden-onset pain, high fixed position, absent cremasteric reflex

Tx: bilateral orchidopexy (both sides as increased risk of torsion in the other side)

Question 10

What is paraphimosis? Causes? Pathophysiology? Mx?

Answer 10

Paraphimosis def: unable to pull back the foreskin

Causes: tight foreskin (phimosis), a complication of urinary catheter (always remember to replace foreskin after withdrawing for catheter insertion)

Pathophysiology: constrictive effect of foreskin –> oedema of distal penis –> ischaemia/necrosis (if severe)

Mx: UROLOGICAL EMERGENCY - must be reduced ASAP

• Reduce with - Lubricating jelly OR dextrose-soaked gauze
• If difficult - needle used to make small holes in penis –> drainage of oedema

Question 11

Prostate cancer - Ix? Mx?

Answer 11

Ix:

• PR exam, PSA
• FBC, U&E, LFTs
• Transrectal ultrasound (TRUS)-guided needle biopsy
  
  • Gleason score = PC grading
  • TNM staging
• Multiparametric MRI

Mx: surgery/radiotherapy

• Radial prostatectomy ± LN dissection
• External beam radiotherapy/brachytherapy
• Androgen-deprivation therapy (ADT)

Question 12

Urinary incontinence - types & Tx?

Answer 12

Stress-incontinence (leak on laugh/cough):

• Pelvic muscle exercises
• Pseudoephedrine (2nd - Duloxetine)
• Retropubic suspension/colposuspension

Urge-incontinence (preceded by the urge to pass urine):

• Bladder retraining
• Anticholinergic e.g. Oxybutynin (not if >80yrs), Tolterodine

Overactive bladder syndrome (urge but not incontinence - increased freq + nocturia): same as urge incontinence