Urinary System Flashcards
1
Q
How is AKI defined?
A
An abrupt reduction in kidney function defined by either:
- An absolute increase in serum creatinine >26umol/l within 48 hours
OR
- >50% increase in serum creatinine from baseline in 7 days
OR
- A 25% fall in eGFR within 7 days (children + young people)
Oligouria <0.5ml/kg/hr for at least 6 hours (8 hours for children)
2
Q
How do you assess the severity of an AKI? (6)
A
- Fluid overload - signs of pulmonary oedema (crackles, expansion breath sounds, dull percussion), JVP, peripheral oedema
- Fluid depletion - postural hypotension, tissue turgor, dry mouth, sunken eyes, cap-refill
- Hypotension >90/60
- Urine output - oliguria or anuria
- Hyperkalaemia - look for ECG signs (tall T waves, flat P waves, broad QRS, sloping ST)
- Acidosis - will cause hyperventilation and cardiac instability
3
Q
80% of AKIs can be resolved by doing what? (3)
A
- Fluid assessment + fluid replacement
- Treat acidosis
- Treat sepsis
4
Q
What can AKI be divided into in terms of categories?
A
Pre-renal
Intrinsic
Post-renal
5
Q
Which of the three categories of AKI is most common?
A
Pre-renal
6
Q
What happens during pre-renal AKI generally?
A
There is reduced perfusion to the kidneys and this leads to a decreased eGFR.
7
Q
What are the causes of a pre-renal AKI? (3)
A
- Hypovolaemia
- Reduced cardiac output
- Drugs
8
Q
What are the causes of reduced cardiac output that can lead to a pre-renal AKI? (4)
A
- Cardiac failure
- Liver failure
- Sepsis
- Drugs
9
Q
Which drugs can lead to a pre-renal AKI? (4)
A
Drugs that reduced blood pressure, circulating volume or renal blood flow
e. g.
1. ACEi
2. ARBs
3. NSAIDs
4. Loop diuretics
10
Q
What are the causes of intrinsic (renal) AKI? (5)
A
- Toxins and drugs
- Vascular
- Glomerular
- Tubular
- Interstitial
11
Q
What are the toxins or drugs that can cause a renal AKI?
A
- Antibiotics
- Contrast
- Chemotherapy
12
Q
What are the vascular causes of renal AKI? (4)
A
- Vasculitis
- Thrombosis
- Athero/thromboembolism
- Dissection
13
Q
What is the glomerular cause of intrinsic AKI?
A
Glomerulonephritis
14
Q
What are the tubular causes of intrinsic AKI? (3)
A
- Acute tubular necrosis
- Rhabdomyolysis
- Myeloma
15
Q
What are the interstitial causes of intrinsic AKI? (2)
A
- interstitial nephritis
2. Lymphoma infiltration
16
Q
What is the main post-renal cause of AKI?
A
Obstruction
17
Q
What are the obstructions that can occur that lead to post-renal AKI? (6)
A
- Renal stones
- Blocked catheter
- Enlarged prostate (BPH)
- Genitourinary tract
- Tumours/masses
- Neurogenic bladder
18
Q
What is the definition of stress incontinence?
A
Involuntary leakage on effort or exertion, or on sneezing or coughing
19
Q
What is urgency urinary incontinence?
A
Involuntary leakage accompanied by, or immediately preceded by, a sudden compelling desire to pass urine which is difficult to defer (urgency). UUI is part of a larger symptom complex known as overactive bladder (OAB) syndrome.
20
Q
What is overactive bladder syndrome?
A
It is urinary urgency (with or without urgency incontinence) which is usually associated with increased frequency and nocturia. OAB may be further described as either, OAB ‘wet’ where incontinence is present or OAB ‘dry’ where incontinence is absent.
21
Q
What is mixed urinary incontinence?
A
Both stress and urgency incontinence; involuntary leakage associated with both urgency and physical stress (exertion, effort, sneezing, or coughing)
22
Q
What is overflow incontinence?
A
Detrusor under activity or bladder outlet obstruction results in urinary retention and leakage of urine. There may be straining to urinate or the person may feel the bladder has been incompletely emptied
23
Q
What are the risk factors for developing stress incontinence? (8)
A
- Increasing age
- Pregnancy and vaginal delivery - muscles and connective tissue can be weakened during delivery, and damage may occur to pudendal and pelvis nerves
- Obesity - due to pressure on pelvic tissues and stretching and weakening of muscles and nerves from excess weight
- Constipation - straining may weaken pelvic floor muscles
- Deficiency in supporting tissue e.g. prolapse, hysterectomy or lack of oestrogen
- Family history
- Smoking
- Drugs - ACEi - by causing cough and worsening stress incontinence
24
Q
What causes urgency urinary incontinence?
A
The symptoms of an overactive bladder are thought to be caused by involuntary contractions of the detrusor muscle during the filling phase of the micturition cycle.
Urgency incontinence is idiopathic in most women.
Some cases are caused by:
1. Parkinson’s disease
2. MS
3. Injury to pelvic/spinal nerves
4. Type 2 diabetes / obesity
25
What can exacerbate urinary urgency? (3)
1. Caffeine
2. Acidic or alcoholic drinks
3. Adverse effects of some dugs - antidepressants and hormone replacement
26
What medications can decrease bladder contractility? (8)
1. ACEi
2. Antidepressants
3. Antihistamines
4. Antimuscarinics
5. Beta-adrenergic agonists
6. CCBs
7. Opioids
8. Sedatives and hypnotics
27
What are the complications of urinary incontinence? (7)
1. Impairment of quality of life
2. Psychological problems (depression, anxiety, embarrassment)
3. Social isolation
4. Sexual problems
5. Loss of sleep (nocturia)
6. Falls and fractures
7. Financial problems (cost of products and laundry)
28
In a history for someone presenting with urge and stress incontinence, what is important to identify?
1. Fluid intake and type of fluids e.g. caffeine, alcohol
2. Symptoms of a more serious diagnosis e.g. haematuria, persisting bladder pain, recurrent UTIs, constant leakage (fistula)
3. Drugs - e.g. ACEi
4. Previous history of spinal surgery, prolapse, hysterectomy, obstetric
5. Systemic disease e.g. diabetes
6. When does the incontinence occur - exertion/coughing or increased frequency and nocturia?
29
How do you assess how severe urinary incontinence is? (4)
Ask:
1. How often is the incontinence - what times, during what activities
2. Use of pads or changing clothes?
3. How often she passes urine including at night
4. Bladder diary for minimum of 3 days - ensuring working and leisure days are included
30
When should a women presenting with incontinence be referred under a 2 week wait pathway?
If she is older than 45 and has unexplained visible haematuria without UTI or after successful treatment of UTI
OR
over 60 with unexplained non-visible haematuria and dysuria or a raised WCC
31
What is the management for stress incontinence? (4)
1. Manage any reversible causes
2. Give lifestyle advice e.g. reduce caffeine intake, reduced weight is BMI >30kg/m
3. Stop smoking
4. Offer referral for 3 months of supervised pelvic floor muscle training (PFMT) - referral to physiotherapy or nurse specialist etc.
32
If the 3 months of pelvic floor exercises do not work for stress incontinence, what can be done next?
Refer to specialist - often treatment options include colposuspension, autologous rectus fascial sling and mesh sling - all surgical
or if prefer drug: duloxetine is second line
33
When should a women presenting with incontinence be preferred to a specialist? (7)
If:
1. Bladder palpable on abdo/bimanual examination
2. Voiding difficulty
3. Pelvic mass that is benign
4. Faecal incontinence
5. Suspected neurological disease
6. Recurrent UTIs
7. Suspected fistula
34
What is the management for urge incontinence AKA urgency urinary incontinence?
1. Lifestyle advice etc.
2. Bladder training (for at least 6 weeks)
3. If symptoms persist despite bladder training:
- anti-muscarinic e.g. Oxybutynin
Tolterodine
35
If an antimuscarinic drug is contraindicated in someone with urge incontinence, what drug can be given instead?
Mirabegron
36
What is important to tell patients who are starting antimuscarinic/drug treatment for urge incontinence?
1. It can take at least 4 weeks to improve symptoms
2. Side effects - dry mouth and constipation - may indicate anticholinergic medication is starting to work
3. Need to be reviewed after 4 weeks
37
What can be offered to a woman who is post-menopausal with vaginal atrophy (dryness)?
Intravaginal oestrogen therapy
38
What can be prescribed to women experiencing troublesome nocturia (e.g. getting up multiple times a night, experiencing insomnia as a result etc)?
Desmopressin
39
NICE 2019 concluded what about desmopressin?
It is useful for nocturia but does not reduce incontinence in women (or there is insufficient evidence anyway) - there is also a risk of hyponatraemia with it.
40
Which form of incontinence is most common in the UK?
Stress incontinence
41
What is overactive bladder most commonly caused by?
Detrusor muscle overactivity
42
How does OAB present? (4)
1. Frequency of micturition
2. Nocturia
3. Abdominal discomfort
4. Urge incontinence (more common in women)
43
How is diagnosis of OAB confirmed?
Urodynamic studies
44
What are the differential diagnoses for OAB? (8)
1. Stress incontinence
2. Functional incontinence
3. Overflow incontinence
4. Urinary fistula
5. Enuresis
6. UTI
7. Diabetes
8. Bladder cancer
45
What investigations are performed in someone with OAB? (4)
1. Urine dipstick
2. Bloods - U&Es, calcium, fasting glucose
3. Urodynamic studies - show involuntary contraction of the bladder during filling
4. USS of the rental tract and cystoscopy may be required
46
What are the management options offered in secondary care to people with OAB (this includes urge incontinence basically) who have tried bladder training and oxybutynin? (3)
1. Botulinum toxin A
2. Nerve stimulation
3. Surgical treatment
47
For someone presenting with any form of incontinence, what investigations should be done? (6)
1. Urine dipstick testing
2. Examination - digital assessment of pelvic floor muscles, in men DRE
3. Post-void residual volume
4. Mid-stream urine for cultures if positive dipstick
5. Renal function tests
6. Urodynamic studies
48
What are the causes of urinary retention - in men and women respectively? (lots)
In men - benign prostatic hyperplasia, meatal stenosis, paraphimosis, penal contstricting bands, phimosis, prostate cancer
In women - prolapse (cystocele, rectocele, uterine), pelvic mass e.g. uterine fibroid, retroverted gravid uterus
In both - bladder calculi, bladder cancer, faecal impaction, GI malignancy, urethral strictures, foreign bodies, stones
49
Up to 10% of acute urinary retention episodes are thought to be attributable to drugs. What are the drugs known to cause it? (8)
1. Anticholingerics (antipsychotics, antidepressants)
2. Opioids and anaesthetics
3. Alpha agonists
4. Benzodiazepines
5. NSAIDs
6. CCBs
7. Antihistamines
8. Alcohol
50
How do you distinguish between acute and chronic urinary retention?
AUR is usually painful, whilst chronic due to its slow nature is relatively pain free.
51
What investigations need to be performed for people presenting with acute urinary retention? (4)
1. Urinalysis
2. MSU
3. Bloods - FBC, U&Es, blood glucose, PSA
4. Imaging studies - USS, CT scan, MRI/CT brain scan/spinal
52
What is the initial management for people presenting with acute urinary retention?
1. Immediate and complete bladder decompression - catheterisation
2. In men - alpha blocker before the removal of the catheter
(Pharmcological treatment for post-operative retention e.g. cholinergic, prostaglandin - these are being explored as alternatives)
53
What is the secondary management for acute urinary retention caused by prostatic enlargement (after catheterisation)?
1. TWOC and an alpha blocker
2. Prostatic surgery
- prolonged catheterisation is associated with an increased morbidity
54
What are the complications of AUR?
1. UTIs
2. AKI
3. Post-obstructive diuresis
4. Post-retention haematuria
55
What can prevent AUR in men with BPH?
5 alpha-reductase inhibitors e.g. finasteride
56
What does obstruction of the ureter lead to?
1. Dilation of the ureter and hydronephrosis
2. Pain (particularly if acute)
3. Decreased renal function due to back pr ensure causing renal tubular atrophy
4. Increased risk of UTI, sepsis and stone formation
57
In someone with an acute upper urinary tract obstruction, how do they present?
1. Flank pain - dull, sharp or colicky, often restless, often radiates to iliac fossa, inguinal area, may have ipsilateral back pain
2. Loin tenderness and enlarged kidney on palpation
3. Symptoms of UTI and signs of sepsis
4. Nausea and vomiting are common with acute obstruction
58
How does acute lower tract obstruction present?
Usually severe suprapubic pain and evidence of distended bladder
59
What are the causes of hydronephrosis?
1. Renal calculi
2. Pregnancy
3. BPH
4. Malignancy
or
PACT
p - pelvic-ureteric obstruction
a - aberrant renal vessels
c - calculi
t - tumours of renal pelvis
60
What are the bilateral causes of hydronephrosis? (5)
SUPER
1. Stenosis of the urethra
2. Urethral valve
3. Prostatic enlargement
4. Extensive bladder tumour
5. Retro-peritoneal fibrosis
61
What investigations are done for someone with hydronephrosis? (4)
1. USS (first line!) - identifies presence of hydronephrosis and can assess kidneys
2. IVU
3. Antegrade/retrograde pyelography
4. CT scan if suspected renal colic
62
How is hydronephrosis managed? (3 - depends on acute or chronic)
1. Remove the obstruction and drainage of urine
2. If acute upper urinary tract obstruction then - nephrostomy tube
3. If chronic upper urinary tract obstruction then - ureteric stent or a pyeloplasty
63
Which type of cancer is most common in the kidneys in adults?
Renal cell carcinoma - accounts for over 80% of neoplasms arising from the kidneys
64
What is the most common cancer in the kidneys in children?
Wilms' tumours
65
Where does renal cell carcinoma (RCC) originate?
From the proximal renal tubular epithelium
66
Which chromosome is associated with RCC?
Chromosome 3 (short arm)
67
How can RCC's be subdivided?
1. Clear cell RCC
2. Papillary
3. Chromophobe
4. Collecting duct carcinoma
...they are in order of prevalence - clear cell accounts for most RCCs
68
In addition to renal cell carcinomas, what are the other tumours that can be found in the kidneys? (6 - but just name 3...if possible)
1. Wilms' tumour
2. Transitional cell carcinoma
3. Angiomyolipoma (commonly seen in patients with tuberous sclerosis)
4. Leiomyosarcoma
5. Sarcoma
6. Adenoma
69
Which age range has the highest incidence of kidney cancer?
60-70 years old
70
What two lifestyle risk factors are associated with renal cancer? (2)
1. Smoking
| 2. Obesity
71
Although now more than 50% of renal cancers are detected through USS when investigating something else, what can be the clinical or presenting features of RCC? (10)
1. Haematuria
2. Loin pain
3. Loin mass
4. Fatigue
5. Weight loss
6. Macroscopic haematuria
7. Varicocele
8. Bilateral ankle oedema
9. Pyrexia of unknown origin
10. Hypertension
72
Where is it common for RCC to metastasise to?
1. Adjacent structures e.g. adrenal glands, spleen, colon or pancreas
2. Lungs - cannon ball mets
3. Bone - it produces osteolytic lesions
73
What investigations are performed for suspected RCC? (8)
1. Urinalysis, cytology, culture
2. Renal function tests - U&Es (however may be normal if one kidney is functioning well)
3. FBC - may detect iron-deficiency anaemia or polycythaemia
4. CT renal scanning
5. Intravenous urogram IVU (not good for clear cell carcinoma though, but will show obstruction)
6. Cystoscopy
7. CXR - for cannon ball mets
8. Renal cell biopsy
74
Why may someone with RCC have polycythaemia?
Some renal tumours produce erythropoietin and increase haematocrit
75
What is the staging used for RCC?
Just TNM
76
For TNM staging in RCC, how is T1 and T2 distinguished?
It is the size of the tumour - T1 <7cm whereas T2 >7cm.
77
Where has T4 for RCC invaded beyond?
Gerota's fascia (collagen-filled, fibrous connective tissue that encapsulates the kidneys and adrenal glands)
78
What is the management of RCC?
Surgery with or without radiotherapy and/or chemotherapy, depending on the stage
- radical nephrectomy is no longer the gold standard curative therapy for patients with localised RCC.
79
What is the first line management for a patient with RCC which is localised and less than 7cm in diameter?
Partial nephrectomy
80
When is it necessary to remove the adrenal gland in someone with RCC?
If they have a large upper pole tumour in which there is a high risk of adrenal invasion
81
Standard chemotherapy is considered ineffective in patients with RCC. What is the recommended treatment alongside surgery in someone with clear cell RCC?
Interferon alpha (IFN-a)
82
What are the intrinsic causes of AKI? (5)
1. Glomerulonephritis
2. Acute tubular necrosis
3. Acute interstitial nephritis
4. Rhabdomyolysis
5. Tumour lysis syndrome
83
What causes acute interstitial nephritis?
Co-amoxiclav is known to cause this (and other penicillin based antibiotics)
84
In the developing world, 90% of bladder cancers are what?
Transitional cell carcinomas
85
What makes up the reminding 10% of bladder cancers?
Squamous cell carcinomas
86
Which sex has a high prevalence of bladder cancer?
Men 3:1 woman
87
What are the risk factors for developing bladder cancer? (6)
1. Increasing age
2. Smoking (half of bladder cancers are caused by smoking - tobacco smoke contains aromatic amines which are renally excreted)
3. Occupational exposure to aromatic amines or aromatic hydrocarbons - industrial plants processing paint, dye, metal etc.
4. Radiation to the pelvis and cyclophosphamide
5. Squamous cell tumours usually follow chronic inflammation from stones or indwelling catheters
6. SCHISTOSOMIASIS
88
How does bladder cancer present? (2)
1. Painless haematuria (80-90% of cases)
- this must be treated as malignancy of the urinary tract until proven otherwise
2. Voiding symptoms
89
What % of people with bladder cancer at diagnosis have metastatic spread?
5%
90
Where does bladder cancer metastasise to most commonly?
1. Lymph nodes
2. Lung
3. Liver
4. Bone
5. Central nervous system
91
What are the referral guidelines for someone with visible haematuria? (3)
Urgent referral:
1. Adults over 45 years with unexplained visible haematuria without UTI
2. Adults over 45 years with visible haematuria that persists or recurs after successful treatment of UTI
3. Adults over 60 with unexplained non-visible haematuria and either dysuria or raised WCC on blood test
92
When is a non-urgent referral indicated for suspected bladder cancer?
In people over 60 with recurrent or persistent unexplained UTIs
93
What are the differentials for bladder cancer? (5)
1. Haemorrhage cystitis
2. Nephrolithiasis
3. Renal cancer
4. Urethral trauma
5. UTI
94
What investigations are performed for suspected bladder cancer? (6)
1. Urinalysis - culture too
2. FBC, U&Es
3. Urine cytology
4. MRI or CT if muscle-invasive bladder cancer is suspected
5. Cystoscopy allows direct inspection and biopsy of suspicious lesions
6. NICE recommended white light-guided TURBT - with one of: photodynamic diagnosis, narrow-band imaging, cytology or a urinary biomarker.
95
During TURBT what should be offered according to NICE guidelines?
Single dose of intravesical mitomycin C
96
When does another TURBT need to be performed after the initial one?
If the first specimen does not contain detrusor muscle
97
How is treatment divided in bladder cancer?
Between non-muscle-invasive bladder cancer and muscle-invasive
98
For intermediate risk non-muscle-invasive bladder cancer, what is the NICE recommended treatment?
A course of at least 6 doses of intravesical mitomycin C
99
For high-risk non-muscle-invasive bladder cancer, what is the treatment?
Choice of:
- Intravesical BCG (Bacille Calmette-Guerin)
OR
- Radical cystectomy
(choice depends on many factors including risk of progression, type, stage and grade of cancer etc)
100
What is intravesical BCG/how does it work?
It is similar to the vaccine used against TB, and its not fully understood how it works but apparently it causes an inflammatory reaction within your bladder than activates immune response to destroy the cancer cells
101
What is the management for muscle-invasive bladder cancer?
Neoadjuvant chemotherapy- combination of cisplatin before radial cystectomy or radical radiotherapy
102
What can be offered to help people with pelvic pain as a result of their bladder cancer?
```
Radiotherapy
or
Nerve block
or
Palliative chemotherapy
```
103
There is thought to be three forms of autosomal dominant polycystic kidney disease (ADPKD), what are they and which chromosome is involved 85% of the time?
PKD1 - chromosome 16 (85%)
PKD2 - chromosome 4 (-15%)
PKD3 - gene locus not identified
104
What % of people on renal dialysis have ADPKD (autosomal dominant polycystic kidney disease)?
10%
105
How does ADPKD present?
Most present with complications of the disease, though more people are being detected due to screening individuals who have an affected relative.
106
What are the complications of ADPKD? (8)
1. Loin pain (most common symptom)
2. Impaired urine concentrating capacity - excessive water and salt loss such as nocturia (common early presentation)
3. Hypertension (common presentation - 60% adults affected)
4. Bilateral kidney enlargement
5. Gross haematuria following trauma is a classic presenting features of ADPKD - it occurs in 30-50% of people. Renal colic due to clots in the collecting system can be severe.
6. UTI and pyelonephritis
7. Renal stones - twice as common
8. Kidney failure
107
Which type of renal stone is most common in people with ADPKD?
Uric acid stones are more common than calcium oxalate stones
108
What are the extra-renal manifestations of ADPKD? (6)
1. Polycystic liver disease- symptoms that can develop as a result of mass effect: dyspnoea, early satiety, GORD, low back pain, ascites, obstructive jaundice
2. Male infertility
3. Pancreatic cysts
4. Arachnoid membrane cysts - can increase risk of subdural haematomas
5. Intracranial berry aneurysms
6. Mitral valve prolapse is found in up to 25% of individuals
109
What is Alport syndrome?
It is a genetic condition characterised by kidney disease, hearing loss and eye abnormalities. Most people will have progressive loss of kidney function resulting in end-stage kidney disease. Additionally they may develop sensorineural hearing loss in late childhood/early adolescence.
110
What are the different treatments for Alport syndrome? (4)
1. Hearing aids
2. Haemodialysis
3. Peritoneal dialysis
4. Kidney transplantation
111
What are the two main causes of acute tubular necrosis?
1. Ischaemia (shock and sepsis)
| 2. Nephrotoxins (aminoglycosides, radio contrast agents, lead, myoglobin secondary to rhabdomyolysis)
112
What are the features of acute tubular necrosis? (2)
1. AKI - raised urea, creatinine and potassium
| 2. Muddy brown casts in the urine
113
What is the screening investigation for relatives with ADPKD?
Abdominal USS
114
What is the diagnostic criteria for ultrasound in patients with a positive family history of ADPKD? (3)
1. Two cysts, unilateral or bilateral, if aged <30 years
2. Two cysts in both kidneys if aged 30-59 years
3. Four cysts in both kidneys in aged >60 years
115
What is the only medical management known to treat ADPKD?
Tolvaptan (vasopressin receptor 2 antagonist) - for certain patients to slow the progression of cyst development and renal insufficiency.
It is only prescribed if:
- they have CKD stage 2-3 at the start of treatment
- there is evidence of rapidly progressing disease
and
-the company provides it with the discount agreed in the patient access scheme
116
As the mainstay of treatment for ADPKD is supportive, what will need to be treated as and when required?
1. Haematuria - normally due to renal colic - and this will be treated with analgesia etc.
2. Hypertension - try to control with a target of 130/80mmHg
3. CKD - dialysis if required
4. Polycystic liver disease - normally nothing needed but sometimes laparoscopic cyst fenestration
117
What is a urethral stricture?
It occurs when part of the urethra becomes narrowed. Any section of the urethra may be affected and it is normally due to scarring of the lining of the urethra and the surrounding corpus spongiosum. They are more common in males than females.
118
What are the symptoms of urethral stricture? (7)
1. Reduced urine flow
2. Spraying of urine or a double stream may occur
3. Frequency
4. Dribbling
5. UTIs
6. Reduced force of ejaculation
7. Dysuria (uncommon)
119
What are the causes of urethral strictures? (2)
1. Trauma leading to scar tissue e.g. post cystoscopy, catheterisation
2 Infection e.g. STI, catheter related
120
What are the complications of urethral strictures? (2)
1. Infections - due to residual urine in the bladder
| 2. Abscess around the stricture
121
What is the treatment for urethral strictures? (3)
1. Dilatation of the stricture - passing a boogie into the urethra
2. Urethrotomy - camera test to view the stricture - the stricture is then cut to widen it 50% will be cured, 50% will have recurrence.
3. Urethroplasy - last line is corrective operation - graft from cheek to form new section of urethra.
122
What is prescribed prophylactically until treatment for urethral stricture has been done?
Antibiotics to prevent UTIs
123
What is urethritis?
It describes urethral inflammation and can be the result of infectious or non-infectious causes but is primarily a sexually acquired disease
124
Male urethritis is divided between two classifications - what are they?
1. Gonococcal urethritis
| 2. Non-gonococcal urethritis
125
What causes gonococcal urethritis?
Neisseria gonorrhoeae
126
What are the organisms that can cause non-gonococcal urethritis? (2)
1. Chlamydia trachomatis
| 2. Mycoplasma genitalium
127
Urethritis is the most common condition diagnosed and treated in men attending GUM clinics in the UK. How many cases are diagnosed each year?
80,000
128
Which form of urethritis is most common - NGU or GU?
NGU - chlamydia
129
How can male urethritis present? (5)
1. Asymptomatic - 95% gonorrhoea, 50% chlamydia
2. Urethral discharge - purulent with or without blood
3. Urethral pruritus, dysuria, penile discomfort
4. Skin lesions (with herpes simplex virus)
5. Systemic symptoms e.g. conjunctivitis/arthritis
130
Which patients are high risk for male urethritis? (6)
1. Sexually active
2. Unprotected vaginal sex
3. MSM
4. More common in cities
5. Age <35 - 40 years
6. Recent partner change
131
What are the differentials for urethritis? (4)
1. Candidal balanitis
2. Epididymo-orchitis
3. Cystitis
4. Acute prostatitis
132
Patients with urethritis should be tested for what other diseases?
HIV, hep B and syphilis
133
What is the treatment for NGU? (2)
1. Doxycycline 100mg BD for 7 days
2. Azithromycin 1g STAT
(if the patient is known to be M.genitalum positive, then azithromycin 500mg stat then 250mg daily for four days)
134
What is the treatment for confirmed gonococcal urethritis?
1. Ceftriaxone 500mg IM
PLUS
2. Azithromycin 1g PO STAT
135
What can be the complications of urethritis? (6)
1. Epididymitis and/or orchitis
2. Prosatitis
3. Systemic dissemination of gonorrhoea
4. Reactive arthritis
5. PID
6. HIV transmission increased
136
What is urolithiasis?
It is the formation of stones anywhere in the urinary tract (the kidneys, ureter or bladder)
137
What is renal or ureteric colic?
Generally describes an acute or severe loin pain caused when a urinary stone moves from the kidney or obstructs the flow of urine through the ureter
138
Why do urinary stones occur?
They form when urine becomes excessively saturated with a mineral, leading to crystal formation - the crystal either passes out or is retain in the kidneys and can grow and form a stone
139
What are the various compositions of urinary stones?
1. Calcium stones - 80% (of which 80% are calcium oxalate and 20% calcium phosphate)
2. Uric acid stones - 10-20%
3. Struvite stones (staghorn) - AKA infection stones, make up 1-5% of urinary stones and result from bacterial infection that hydrolyses urea to ammonium
4. Cystine - 1%
5. Drug-induced stones - 1%
140
What are struvite stones normally composed of? (3)
1. Magnesium
2. Ammonium
3. Phosphate
141
What are the risk factors for developing urinary stones?
1. Age and gender - middle aged men (3:1)
2. Ethnicity - caucasians
3. Diet - excessive dietary intake of oxalate, urate, sodium and animal protein
4. Chronic dehydration
5. Obesity
6. Environmental factors - high ambient temperatures = fluid status/urine volume
7. Family history - twice as likely to develop them with a positive family history
8. Horseshoe kidney and other anatomical features
142
What % of people will experience a recurrent stone formation at 5 years post-original one?
50% ..and 80% at 10 years
143
What the complication of renal/ureteric stones?
1. Obstruction of urinary flow - hydronephrosis and decreased eGFR --> can lead to irreversible kidney damage
2. Obstruction leading to infection causing obstructive pyelonephritis --> sepsis
3. Renal carcinoma
4. CKD
5. Coronary heart disease
144
How can someone with urinary stones present? - in a SOCRATES format
S: Unilateral abdominal pain originating in the loin or flank rand radiating to the labia in women or the groin/testicle in men
O: Abrupt onset
C: Spasmodic severe pain with intervals of no pain or dull ache (often described as worst pain ever experienced)
R: Loin to groin
A: Nausea, vomiting and haematuria, dysuria, urinary frequency, and straining
T: Pain typically lasts minutes to hours
E:
S: 9/10, 10/10
145
What are the top differentials when considering urinary stones? (5)
1. Ruptured AAA
2. Appendicitis
3. Diverticulitis
4. Peritonitis
5. Complicated UTI
146
On examination what would indicate diagnosis of urinary stones rather than the other differentials?
1. Restless and unable to lie still - this excludes peritonitis
2. Hesitancy of micturition - suggest urinary tract obstruction
3. Fever and sweats - coexisting UTI/infection as a result of stones
147
What test could you do in GP land if someone presents with urinary stones?
Urine dipstick - haematuria, nitrites/leucocytes
148
When should someone with urinary stones be admitted to hospital immediately from GP land? (3)
1. Signs of infection e.g. fever, sweats, sepsis
2. Increased risk of AKI - e.g. pre-existing CKD or bilateral obstructing stones
3. Person is dehydrated and cannot take oral fluids due to N&V
149
What imaging should all adults with suspected urinary stones have within 24 hours of presentation?
1. Non-contrast CT (first line) (non-contrast because the stones are white and if contrast was used it would mask the stones!)
2. If pregnant woman or children - USS
150
What pain relief is recommended for people with urinary stones?
1. NSAIDs
2. IV paracetamol
3. Consider tramadol if above two are contraindicated
Do NOT offer antispasmodics
151
What is the medical management for urinary stones <10mm in size?
Alpha blockers can help facilitate the spontaneous passage of the stone
152
What are the surgical options to help remove renal/ureteric stones?
1. Shock wave lithotripsy (SWL) a non-invasive outpatient treatment using shock waves to break up the stone and let is pass spontaneously
2. Percutaneous nephrolithotomy (PCNL) - nephroscope is passed percutaneously into the collecting duct and the stone is fragment and extracted through the nephroscope
3. Ureteroscopy (laser removal)
4. Open surgery
153
What dietary advice can be offered to help reduce risk of recurrence?
1. Increase fluid intake
2. Add fresh lemon to drinking water and avoid carbonated drinks
3. Reduce salt intake
4. Do not restrict dietary salt intake
5. Consider thiazide treatment for adults with recurrence after restricting their sodium intake
154
Why is lemon juice added to water recommended to reduce stone formation?
Lemon juice is high in citrate, leading to higher concentrations of citrate in urine. This may stop calcium from binding to other stone constituents.
155
When is SWL (shock wave lithotripsy) recommended by NICE?
First line surgical treatment: stones less than 10mm
156
What is the first line treatment for acute pyelonephritis in non-pregnant women and men?
Cefalexin 500mg BD (7-10 days)
157
Renal cell carcinoma are what type of cancer histologically?
Adenocarcinoma
158
Renal cell carcinoma is an adenocarcinoma of the renal cortex, where is it believed to arise from?
The proximal convoluted tubule
159
How do renal adenocarcinomas appear - there is a 20% rule which them in terms of 3 different presentations?
They are usually solid tumours
- 20% may be multifocal
- 20% may be calcified
- 20% may have a cystic component
160
How can renal cell carcinoma (adenocarcinoma) present?
1. Haematuria (50%)
2. Loin pain (40%)
3. Mass (30%)
4. Metastasis symptoms (25%)
(<10% have classic triad of haematuria, pain and massO)
161
What are the features of rhabdomyolysis? (7)
1. AKI with disproportionately raised creatinine
2. Elevated CK
3. Myoglobinuria
4. Hypocalcaemia (as myoglobin binds to calcium)
5. Elevated phosphate
6. Hyperkalaemia
7. Metabolic acidosis
162
What are the causes of rhabdomyolysis (5)
1. Seizure
2. Collapse/coma (long lie)
3. Crush injury
4. Running marathon
5. Drugs (statins if co-prescribed with clarithromycin)
163
What is the management for rhabdomyolysis?
1. IV fluids
| 2. Urinary alkalinization is sometimes used
164
What is the gold standard investigation for bladder cancer diagnosis?
Cystoscopy
165
In someone with a moderate flare up of UC whose daily rectal aminosalicylate is not working what is the most appropriate drug to add in the current therapy?
Oral aminosalicylate
166
Which drug treatment is associated with hyaline casts being seen on urine microscopy?
Furosemide - loop diuretics (hyaline casts can also be seen in healthy people who do strenuous exercise)
167
What is associated with brown granular casts in urine?
Acute tubular necrosis
168
Red cell casts on urine microscopy is associated with which syndrome?
Nephritic syndrome
169
If someone experiences recurrent balanitis, each time testing negative for STI and bacterial infections, what is the management?
Circumcision - as chronic balanitis can result in stricture formation that can lead to penile cancer and paraphimosis
