Urology Flashcards
1
Q
What are the three functions of the urinary tract?
A
- To collect urine produced by the kidneys
- To store urine collected safely
- To expel urine when socially acceptable
2
Q
Where are the kidneys situated?
A
Retroperitoneal, between T11-L3
3
Q
Where do the kidneys get their blood supply from?
A
Renal artery, which comes directly from the aorta at L1 level
4
Q
Where is the prostate gland situated?
A
At the neck of the bladder
5
Q
What are the four nerves controlling the bladder and sphincter?
A
- Pelvic nerve (involuntary)
- Hypogastric plexus (involuntary)
- Pudendal nerve (voluntary)
- Afferent pelvic nerve (sensory)
6
Q
Which neurotransmitters are used in control of the bladder and sphincter?
A
ACh via the pelvic (parasympathetic) and pudendal (somatic) nerves.
Noradrenaline via the hypogastric plexus (sympathetic).
7
Q
The afferent pelvic nerve carries sensory signals from which muscle?
A
Detrusor
8
Q
Which parts of the brain control coordination of voiding?
A
Pontine micturition centre/periaqueductal grey
9
Q
What controls the micturition reflex?
A
Sacral micturition centre
10
Q
What controls the guarding reflex?
A
Onuf’s nucleus
11
Q
What are the three phases of voiding?
A
Storage phase (98% of the time) Guarding reflex (if micturition inappropriate) Micturition reflex (if micturition appropriate)
12
Q
Why does the pressure in the bladder remain low as the volume increases?
A
Due to receptive relaxation and detrusor muscle compliance
13
Q
What do the nerves supplying the urinary tract do during the filling phase?
A
- Afferent pelvic nerve sends slow firing signals to the pons via the spinal cord
- Sympathetic stimulation via the hypogastric plexus maintains detrusor muscle relaxation
- Pudendal nerve stimulation maintains urethral contraction
14
Q
Describe the micturition reflex
A
- Higher volumes in the bladder stimulate the afferent pelvic nerve to send fast signals to the sacral micturition centre in the sacral spinal cord
- The pelvic parasympathetic nerve is stimulated and the detrusor muscle contracts
- The pudendal nerve is inhibited and the external sphincter relaxes
15
Q
Describe what happens during bladder emptying
A
- Coordinated detrusor contraction with external sphincter relaxation expels urine from the bladder
- A positive feedback loop is generated until all the urine is expelled
- Once complete, the detrusor relaxes and the external sphincter contracts.
16
Q
Describe the guarding reflex
A
- Occurs when voiding is inappropriate, which is determined by afferent signals from the pelvic nerve being received by the PMC and PAG and being transmitted to higher cortical centres
- Sympathetic (hypogastric) nerve stimulation results in detrusor relaxation
- Pudendal nerve stimulation results in contraction of the external urethral sphincter
17
Q
What are the lower urinary tract symptoms related to storage?
A
Frequency
Urgency
Nocturia
18
Q
What are the lower urinary tract symptoms related to voiding?
A
Weak/intermittent stream Incomplete emptying Straining Hesitancy Terminal dribbling
19
Q
What is benign prostatic hyperplasia?
A
Increased number of cells in the prostate, caused by epithelial and stroma proliferation or decreased apoptosis
20
Q
What is benign prostatic enlargement?
A
Enlarged prostate found during physical examination/urological investigation
21
Q
What can contribute to BPH?
A
Androgens, oestrogen, stromal epithelial interactions, growth factors and neurotransmitters
22
Q
What is the role of androgens in BPH?
A
- Do not actually cause it, but required for BPH to occur.
- Androgen withdrawal can involute established BPH
- If androgen action/production is completely inhibited, BPH does not occur.
23
Q
What is active benign prostatic obstruction?
A
Obstruction caused by contraction of the alpha-1 adrenoreceptor mediated smooth muscle
24
Q
What is passive benign prostatic obstruction?
A
Obstruction caused by the volume effect of BPE
25
What scoring system can be used to assess patients with prostate-related symptoms?
IPSS - International Prostate Symptom Score, consists of 7 questions, graded 0-5
26
What are the first line investigations for a male patient with lower urinary tract symptoms?
- General examination
- Abdominal examination
- External genitalia examination (check for e.g. phimosis, meatal stenosis)
- Digital rectal examination (check for inner tone, prostate size/consistency, palpable nodules)
- Focused neurological examination
- Urinalysis (UTI/haematuria)
27
What are the second line investigations for a male patient with lower urinary tract symptoms?
- Flow rates and residual volume
- Frequency volume chart
- Renal biochemistry
- Imaging
- PSA?
- TRUSS (transrectal ultrasound)
- Urodynamics (in some cases)
28
What are the possible complications of BPH?
- Infections
- Stones
- Haematuria
- Acute retention
- Chronic retention
- Interactive obstructive uropathy
29
How is acute urinary retention treated?
Self-catheterisation or bladder outflow surgery
30
What symptom should alert the clinician to the risk of obstructive uropathy?
Nocturnal enuresis
31
What are the long term treatment options for obstructive uropathy?
Surgery (TURP) or indwelling catheter
32
Name two types of drugs that can be used to treat the symptoms of BPH
Alpha-adrenergic antagonists
| 5-alpha-reductase inhibitors
33
Name two alpha-adrenergic antagonists
Tamsulosin
| Doxazosin
34
How do alpha-adrenergic antagonists help with the symptoms of BPH?
Promoting relaxation of the muscles around the prostate and bladder to allow increased flow of urine.
35
Name two 5-alpha-reductase inhibitors
Finasteride
| Dutasteride
36
How do 5-alpha-reductase inhibitors help with the symptoms of BPH?
Inhibiting the conversion of testosterone to dihydrotestosterone (more active form), which results in a decrease in prostate size
37
Why would you normally start a patient on both an alpha-adrenergic antagonist and a 5-alpha-reductase inhibitor and then stop the alpha-adrenergic antagonist after 6-9 months?
The alpha-adrenergic antagonist gets to work faster, but only the 5 alpha-reductase-inhibitor will actually prevent symptomatic progression so best to start the AAA alongside the 5ARI until the 5ARI has had a chance to work.
38
What are the indications for surgery in patients with BPH?
- Bladder stones
- Recurrent gross haematuria
- Recurrent infections
- Therapy failure
39
What are the early complications of transurethral resection of prostate?
- Bleeding
- Sepsis
- Post TUR syndrome
- Retention (formation of clots inside catheter)
40
What are the late complications of transurethral resection of prostate?
- Retrograde ejaculation (all patients)
- Delayed bleeding
- Urethral stricture
- Bladder neck contracture
- Urinary incontinence
- Erectile dysfunction
41
What is a neuropathic bladder?
A bladder with dysfunctional voiding due to damage to the innervation
42
What things need to be assessed when investigating neuropathic bladder?
- Underlying cause (e.g. level and completeness of injury in spinal cord injury)
- Bladder sensation
- Incontinence (all the time?)
- Urgency
- UTI
- Haematuria
- Bowel function
- Sexual function
- Urinalysis +/- MSU
- USS renal tracts with post void residual measurement (check for signs of hydronephrosis and completeness of emptying)
- Flexible cystoscopy (can present with bladder stones)
- Video urodynamics
43
How is detrusor pressure calculated in video urodynamics?
A pressure transducer in the rectum measures the intra-abdominal pressure and a dual lumen pressure transducer in the bladder measures intra-vesical pressure. Detrusor pressure = intra-abdominal pressure - intra-vesical pressure
44
What should the detrusor pressure line look line on a urodynamic trace?
It should be completely flat until the patient is asked to pass urine and return to normal afterward.
45
How does a urodynamic study inform about bladder compliance?
Bladder compliance is the ability of the bladder to change volume without alteration in detrusor pressure.
46
Why is detrusor pressure >40 considered a problem?
Risks damage to the upper urinary tracts
47
What is reflex bladder?
A type of neuropathic bladder condition whereby the reflex cycle for micturition is intact.
48
What two issues can occur with reflex bladder?
1. Detrusor overactivity (detrusor contracts when it shouldn't)
2. Detrusor-sphincter dyssenergia (sphincter doesn't open early enough so detrusor keeps contracting until sphincter opens or until pressure overrides sphincter)
49
What is the main symptom of detrusor overactivity?
Urgency
50
What is the main symptom of detrusor-sphincter dyssynergia?
Only passing a small amount of urine
51
Why is detrusor-sphincter dyssynergia unsafe?
Risks upper UT damage
52
What is an areflexic bladder?
An acontractile bladder with no innervation to the detrusor, leading to retention.
53
Suprapontine lesions can be caused by cerebrovascular accident, dementia, cerebral palsy and brain tumours. What effect will these have on the bladder?
The inhibitory effect on the micturition centre will be lost, leading to storage symptoms and urgency etc.
54
Suprasacral lesions are most commonly caused by spinal cord injury and multiple sclerosis. What effect will these have on the bladder?
Micturition reflex is preserved but coordination and inhibition of the reflex is disrupted.
55
Sacral/infrasacral lesions can be caused by spina bifida, multiple sclerosis and trauma. What effect will these have on the bladder?
More likely to result in acontractile bladder. Dysfunction depends on level of the injury and whether complete or incomplete.
56
What are the 4 treatment options for neurogenic detrusor overactivity?
1. Anticholinergic treatment
2. Intravesical Botox + intermittent catheterisation
3. Augmentation cystoplasty
4. Ileal conduit
57
What are the 5 treatment options for detrusor sphincter dyssynergia?
1. CISC (clean intermittent self catheterisation)
2. Suprapubic catheter
3. Sphincterotomy
4. Augmentation cystoplasty +/- Mitrofanoff
5. Ileal conduit
58
What are the management options for areflexic bladder?
1. CISC (primary)
2. Suprapubic catheter
3. Sphincterotomy
4. Ileal conduit
5. Autologous fascial sling (if patient has stress incontinence)
59
What neuropathic bladder treatment is always the last resort and why?
Ileal conduit, due to the risk of infection and bleeding
60
What is autonomic dysreflexia?
A potentially life-threatening condition that can occur in patients with spinal cord injury at T6 or higher.
A noxious stimulus (e.g. tight clothing, pressure sore, faecal impaction, blocked catheter/full bladder/UTI) triggers a sympathetic response (tachycardia, sweating, flushing, increased BP, headache). The parasympathetic response is not enough to override the sympathetic response below the level of the injury, so results in vasodilation etc. above the injury but vasoconstriction etc. below the injury.
61
How is autonomic dysreflexia managed?
1. Sit the patient upright to get gravity on your side
2. 2 sprays of sublingual GTN to reduce blood pressure
3. Treat noxious stimulus e.g. remove tight clothing, empty bladder, disimpact bowel
4. Administer 5-10mg nifedipine if more time required to treat stimulus
5. Contact anaesthetists - if ongoing assessment required, may require spinal anaesthetic.
62
What is urinary incontinence?
Involuntary loss of urine
63
What are the common causes of urinary incontinence?
```
DIAPERS:
Delirium/dementia
Infection
Atrophic vaginitis/urethritis
Pharmaceuticals/psychiatric causes
Endocrine causes
Restricted mobility
Stool impaction
```
64
What is overflow incontinence?
Caused by retention, occurs as pressure overcomes the sphincter
65
What is the most common cause of continuous incontinence?
Vesico-vaginal fistula
66
What form is used to work out how severe incontinence is?
ICIQ
67
What should be assessed when taking history for urinary incontinence?
Onset, triggers, haematuria, obs and gynae history, past medical history, smoking status, bowel function, sexual function, bladder diary
68
What should be carried out during examination of a patient who presents with urinary incontinence?
Abdominal/pelvic examination, cough test, digital rectal examination, lower limb neurological examination, urinalysis +/- MUS, post void residual scan
69
What is urge urinary incontinence?
Involuntary loss of urine preceded by sudden urgency
70
What conservative measures can be used to improve the symptoms of urge incontinence?
Reducing caffeine intake, spicy foods, citrus drinks, weight loss, smoking cessation, bladder training
71
What may improve urge incontinence in patients with atrophic vaginitis?
Topical oestrogen cream
72
How do anticholinergic drugs such as oxybutynin and solifenacin reduce the symptoms of urge incontinence?
By inhibiting the muscarinic receptors in the detrusor muscle, thereby inhibiting detrusor contraction.
73
What is the second line pharmacological treatment for urge incontinence?
B3 agonists e.g. mirabegron, vibebegron - inhibit detrusor contraction
74
What is often seen on urodynamics in patients with urge incontinence?
'Bumps' of detrusor activity
75
What are the two options for surgical treatment of urge incontinence if pharmacological management is ineffective?
1. Intravesical Botox
| 2. Sacral neuromodulation
76
What is stress urinary incontinence?
Involuntary loss of urine during activities that increase intra-abdominal pressure
77
What are the risk factors for stress urinary incontinence?
Age, obesity, parity (vaginal delivery, use of forceps), chronic constipation, chronic cough, vaginal prolapse
78
What is stress urinary incontinence usually caused by?
Urethral hypermobility, intrinsic sphincter deficiency or a combination of both
79
What conservative measures can be used to help with stress incontinence?
Lifestyle modifications e.g. smoking cessation, avoiding constipation, weight loss, reduction of caffeine intake
Pelvic floor muscle therapy
Containment e.g. pads, catheterisation
80
Duloxetine is an SNRI that relaxes the bladder and increases sphincter resistance. However, it is rarely used to treat stress incontinence now. Why?
Significant side effects reported by 24% of patients and increased rate of suicide.
81
What are the invasive treatment options for stress incontinence?
Urethral bulking agents
Buch colposuspension
Autologous fascial sling
Synthetic mesh tapes (scandal)
82
What is the most common cause of stress urinary incontinence in males?
Prostatectomy (can also be caused by TURP, pelvic radiotherapy and pelvic surgery)
83
How is male stress urinary incontinence treated?
Initially with pelvic floor muscle training
| Gold standard management is an artificial urinary sphincter
84
What type of renal carcinoma is the most common?
Renal cell carcinoma
85
Other than renal cell carcinoma, what are two other types of kidney cancer?
Transitional cell carcinoma
| Squamous cell carcinoma (very rare)
86
What can cause nephroblastoma in children?
Wilm's tumour
87
Name two types of benign renal masses
1. Oncocytoma
| 2. Angiomyolipoma
88
What type of cancer is renal cell carcinoma?
Adenocarcinoma
89
What are the risk factors for renal cell carcinoma?
Smoking, obesity, renal failure, hypertension, social deprivation
90
Where does renal cell carcinoma often metastasise to?
Lungs - 'cannon ball' metastases, also local invasion (blood vessels, adrenal gland).
91
How does renal cell carcinoma present?
```
Most found incidentally (asymptomatic)
Can present with:
Haematuria
Loin pain
Palpable mass
Systemic symptoms e.g. fatigue, weight loss, bone pain etc.
```
92
Paraneoplastic syndromes are weird bodily effects caused by cancer. What are some of the effects?
Anaemia, polycythaemia, hypertension, hypercalcaemia, hypoglycaemia, Stauffer's syndrome
93
What investigations should be carried out for suspected renal cell carcinoma?
FBC, U&E, LFT, coagulation
CT scan
Needle biopsy may be required to confirm diagnosis but if the tumour is large, should be operated on regardless
94
What is the gold standard treatment for small tumours confined to the kidney?
Partial nephrectomy
95
Why should renal cell carcinoma not be treated with radiotherapy?
Renal cell carcinoma is not radiosensitive
96
What is the operation for upper tract transitional cell carcinoma?
Nephroureterectomy - have to take out the entire ureter and maybe even part of the bladder too to avoid recurrence
97
What is the most common type of bladder cancer in the UK?
Transitional cell carcinoma
98
What is the most common type of bladder cancer in Egypt and why?
Squamous cell carcinoma due to endemic schistosomiasis
99
What are the risk factors for bladder cancer?
Smoking, dyes, carcinogens, PAHs, diesel exhaust, industrial exposure (leather workers, drivers, hairdressers), drugs (phenacetin, cyclophosphamide, pioglitazone)
100
What are the 4 stages of transitional cell carcinoma?
T1 - non-invasive/subepithelial only (low risk)
T2 - muscle invasive
T3 - through the muscle, invading perivesical fat
T4 - invading prostate/pelvic side wall (lethal)
101
To where does transitional cell carcinoma tend to metastasise?
Liver, lungs, bone, adrenal glands
102
How does bladder cancer normally present?
Painless visible haematuria with lower urinary tract symptoms (frequency/urgency/nocturia/recurrent UTI), may be palpable mass in lower abdomen (abdominal examination/DRE)
103
What procedure can be used to investigate the cause of haematuria?
Flexible cystoscopy
104
Why is USS KUB more likely to be performed than CT urogram even though it's less sensitive for the upper tract?
Safety - CT urogram requires a lot of radiation and contrast
105
What are the common urological causes of non-visible haematuria?
BPH, cancer (bladder, kidney, prostate), stone disease, infection (haemorrhagic cystitis)
106
What are the possible nephrological causes of non-visible haematuria?
IgA nephropathy, thin basement membrane disease, glomerulonephritis, vasculitis, Henoch-Schoenlein purpura
107
What is the standard surgical treatment for non-invasive bladder cancer?
TURBT - transurethral resection of bladder tumour
108
What are two intravesical therapies for bladder cancer?
1. Mitomicin C (chemo)
| 2. BCG
109
What can be used to treat muscle invasive bladder cancer?
Radical surgery (cystoprostatectomy/cystourethrectomy and lymphadenectomy) with diversion/reconstruction e.g. ileal conduit + chemotherapy (neoadjuvant or adjuvant)
Radiotherapy for patients unfit for surgery/palliative care
110
What is the most common solid cancer in men aged 20-45?
Testicular cancer
111
How does testicular cancer normally present?
Usually with a painless lump
| Some present with symptoms suggestive of advanced disease
112
What investigations should be carried out for suspected testicular cancer?
```
Scrotal USS
Tumour markers (AFP, beta-HCG, LDH)
Chest x-ray, CT scan abdomen and pelvis +/- chest
```
113
How is testicular cancer managed?
Radical inguinal orchidectomy
Chemotherapy (very sensitive to platinum based chemo)
Retroperitoneal lymph node dissection
114
Name 8 functions of the kidney
1. Waste excretion
2. Electrolyte balance
3. ECF volume regulation
4. Blood pressure regulation
5. Acid-base balance
6. PTH target
7. Red blood cell numbers (EPO)
8. Gluconeogenesis promotion (late response)
115
What are the two types of nephrons in the kidney?
1. Cortical nephrons - short loops, glomeruli in outer cortex
2. Juxtamedullary nephrons - glomeruli border on medulla, long loops, paired with vasa recta
116
What are the two capillary beds in the kidney?
1. Glomerulus (high hydrostatic pressure, rapid fluid filtration)
2. Peritubular capillaries (lower hydrostatic pressure, rapid fluid reabsorption)
117
What is the vasa recta?
Specialised blood supply around the juxtamedullary nephrons supplying the counter current blood flow around the loop of Henle.
118
What effects does changing afferent and efferent arteriolar resistance in the kidney?
1. Modifies hydrostatic pressure in the capillary beds
| 2. Alters glomerular filtration rate, tubular reabsorption or both
119
What three things influence the glomerular filtration rate?
1. Net filtration pressure (derived from hydrostatic pressures and colloid osmotic pressures)
2. Renal blood flow
3. Filtration coefficient Kf (measure of how well the membrane structure is filtering)
120
What forces move fluid out at the glomerulus?
1. Capillary pressure
| 2. Interstitial fluid colloid and oncotic pressure
121
What forces move fluid in at the glomerulus?
1. Plasma colloid oncotic pressure (from albumin)
| 2. Interstitial fluid pressure
122
How is net filtration pressure calculated?
Glomerular hydrostatic pressure - (capsular hydrostatic pressure + blood colloid osmotic pressure)
123
Describe how tubuloglomerular feedback works to restore a drop in glomerular filtration rate.
Macula densa cells (between the afferent and efferent arterioles) sense a decrease in NaCl, secrete prostaglandins, afferent arteriole dilates, increasing blood flow and restores GFR
Also, juxtaglomerular cells release renin, activates RAAS pathway, angiotensin II causes vasoconstriction at efferent arteriole, which also increases GFR.
124
Why should NSAIDs not be used by patients with renal impairment?
NSAIDs inhibit prostaglandin synthesis, which interferes with the tubuloglomerular feedback mechanism.
125
What is the minimum estimated GFR that a person should have?
90ml/min
126
Name two drugs that inhibit tubular secretion of creatinine
Cimetidine, trimethoprim
127
What is creatinine and why is it used to estimate glomerular filtration rate?
Creatinine is a waste product made by the muscles. It is normally filtered out of the blood by the kidneys. Therefore, if serum creatinine levels are high, this can indicate poor filtration by the kidneys.
128
Name three things that decrease GFR by decreasing Kf
1. Renal disease
2. Diabetes mellitus
3. Hypertension
129
How do the kidneys regulate ECF volume?
Increased blood volume results in increased blood pressure. The kidneys respond by increasing renal excretion and normal volume is restored.
130
What is atrial natriuretic peptide and what effect does it have on the kidney?
ANP is secreted by the heart in response to atrial stretch as a result of high blood pressure. It triggers dilation of the afferent arteriole to increase GFR and also inhibits renin secretion, leading to a subsequent decrease in angiotensin II and aldosterone secretion, a decrease in sodium reabsorption, increase in water secretion, increase in diuresis and a decrease in ECF volume.
131
What is chronic kidney disease?
Abnormalities of kidney structure or function, present for over three months, with implications for health.
Abnormal function defined as eGFR < 60ml/min/1.73m2 or albuminuria (urine albumin creatinine ratio > 3mg/mmol)
Abnormal structure as seen on histology or radiology
132
What is used to determine the level of proteinuria?
Albumin creatinine ratio
133
How do patients with chronic kidney disease usually present?
Usually asymptomatic, found incidentally through screening of patients with comorbidities.
Occasionally presents with unexplained haematuria or oedema
134
Name 6 of the more common causes of chronic kidney disease
1. Diabetes
2. Chronic glomerulonephritis
3. Cystic disease
4. AKI
5. Obstructive uropathy
6. Hypertension
135
Name two non-modifiable risk factors for progression of chronic kidney disease.
1. Race
| 2. Underlying cause of renal disease
136
Name some modifiable risk factors for progression of chronic kidney disease.
1. Blood pressure
2. Level of proteinuria (can use ACE inhibitors)
3. Exposure to nephrotoxins (e.g. medications)
4. Underlying disease activity
5. Further renal insults
6. Dyslipidaemia (treat with statins)
7. Increased phosphate
8. Acidosis
9. Anaemia
10. Smoking
11. Glycaemic control if diabetic
137
How many CKD stages are there?
5
138
At what stage of CKD would discussion start regarding the options of haemodialysis, peritoneal dialysis and transplantation?
3/4
139
At what point would a patient be sent to the renal clearance clinic to start preparing for renal replacement therapy/transplant?
eGFR < 20
140
What drugs can be used to treat CKD?
Diuretics to treat salt and water retention
| Sodium binders to bind sodium in the gut
141
Why is dialysis not a perfect physiological replacement for a kidney?
It cannot activate vitamin D, produce erythropoietin or allow complete physiological correction.
142
What is glomerulonephritis?
A broad term that refers to a group of parenchymal kidney diseases that cause inflammation and damage to the glomeruli
143
How can we tell if podocytes aren't working properly?
Protein ends up in the urine
144
What three things can be caused by glomerulonephritis?
1. Leaky glomeruli, resulting in haematuria and proteinuria
2. High blood pressure
3. Deteriorating kidney function
145
Name 6 different presentations of glomerulonephritis.
1. Acute nephritic syndrome
2. Nephrotic syndrome
3. Asymptomatic urinary abnormalities
4. Chronic glomerulonephritis
5. Macroscopic haematuria
6. Nephritic syndrome
146
What are the clinical features of acute nephritic syndrome?
1. Rapid deterioration in kidney function
2. Haematuria and proteinuria on urine dipstick
3. Oliguria, hypertension and fluid overload
147
Name 5 causes of acute nephritic syndrome
1. ANCA associated vasculitis
2. Goodpastures disease (anti-glomerular basement membrane antibodies)
3. Autoimmune: SLE/systemic sclerosis
4. Post-streptococcal infection
5. Crescentic IgA nephropathy/Henoch Schonlein purpura
148
What might you see on fundoscopy of a person with acute nephritic syndrome?
Flame haemorrhages on retina due to bleeding as a result of hypertension.
149
What is (non-acute) nephritic syndrome?
Part of a systemic disease - ANCA associated vasculitis
150
Who is most likely to have nephritic syndrome?
Caucasians aged 50-70
151
How is nephritic syndrome diagnosed?
Systemic inflammatory features with evidence of other organ involvement
ANCA positive
Biopsy shows segmental glomerular necrosis with crescent formation, active lesions, fibrosis and tubular atrophy
152
How is nephritic syndrome treated?
Immunosuppression with steroids and cyclophosphamide to start with, maintenance with azathioprine/rituximab.
153
What is IgA nephropathy?
Nephropathy caused by build-up of IgA deposits in the kidneys, which results in local inflammation.
154
How does IgA nephropathy usually present?
Episodic macroscopic haematuria, usually in 20s-30s, many cases identified as a result of asymptomatic urine testing.
155
How is IgA nephropathy diagnosed?
Biopsy - will show diffuse mesangial IgA deposits, sometimes subendothelial and subepithelial deposits can be seen on electron microscopy.
156
How is IgA nephropathy treated?
```
Supportive care (BP control with RAAS inhibitors, diet, lower cholesterol)
Immunosuppression with steroids, cyclophosphamide and maintenance with azathioprine.
```
157
What is lupus nephritis?
Inflammation of the kidney caused by systemic lupus erythematosus
158
How is lupus diagnosed?
AMA antibody test
159
Proliferative lupus nephritis is the most severe type. How is it treated?
Steroids, cyclophosphamide for 3 months followed by azathioprine.
160
How is membranous lupus nephritis treated?
Supportive care, steroids and possibly cyclophosphamide and azathioprine, but evidence for this is weak.
161
What is nephrotic syndrome?
A condition that causes the kidneys to leak large amounts of protein into the urine.
162
What are the features of nephrotic syndrome?
```
Heavy proteinuria
Hypoalbuminaemia
Oedema
Hypercholesterolaemia
Frothy urine
Swollen ankles
```
163
What is almost always the cause of nephrotic syndrome in children?
Minimal change nephropathy
164
Name 3 primary causes of nephrotic syndrome (i.e. podocyte disease)
1. Minimal change nephropathy
2. Membranous nephropathy
3. Focal segmental glomerulosclerosis
165
Name 7 secondary causes of nephrotic syndrome
1. Diabetes
2. Amyloidosis
3. Infection
4. SLE
5. Drugs
6. Malignancy
7. Scarring
166
How is nephrotic syndrome managed?
1. Establish cause (usually with renal biopsy in adults)
2. Treat complications and manage fluid state (diuretics, ACEI/ARBs, spironolactone)
3. Treat underlying cause
167
What investigations need to be carried out for nephrotic syndrome?
Renal biopsy + investigations to establish underlying cause:
Serum albumin, creatinine, lipids and glucose, urinalysis
Urine protein creatinine ratio (quantify proteinuria)
ANA, DNA antibody, C3 and C4 (lupus)
Antiphospholipase A2 receptor antibody (membranous)
HepBsAg, HepCAb to diagnose Hep B/C associated glomerular disease
168
What happens in membranous glomerulonephritis?
The glomerular capillary wall thickens and IgG and complement deposits in subepithelial surface, resulting in a leaky glomerulus.
169
How is membranous glomerulonephritis diagnosed?
Serum PLA2R antibody ( present in most cases) + renal biopsy
170
How is membranous glomerulonephritis managed?
Mostly supportive treatment - nearly 50% of patients will recover with only blood pressure treatment
Control of oedema, hypertension, hyperlipidaemia and proteinuria
May require immunosuppression with steroids and cyclophosphamide.
171
How is minimal change disease diagnosed?
Renal biopsy appears normal but fused podocytes on electron microscopy.
Don't need to perform biopsy in children because any presentation of nephrotic syndrome is almost certainly minimal change disease.
172
Describe the natural history of minimal change disease.
It has a relapsing-remitting course, but does not progress to renal failure.
173
How is minimal change disease managed?
First line treatment: steroids
Second line treatment: cyclophosphamide/cyclosporine
Some evidence for rituximab
174
What are the three types of pathophysiology that cause erectile dysfunction?
1. Neurogenic = failure to initiate
2. Arteriogenic = failure to fill
3. Venogenic = failure to store
175
Name 8 causes of erectile dysfunction
1. Age
2. Diabetes
3. Coronary artery disease
4. Dyslipidaemia
5. Hypogonadism
6. Trauma
7. Drugs
8. Psychosomatic causes
176
What needs to be checked when assessing a patient with erectile dysfunction?
- Height, weight, BMI
- Thyroid function, pulmonary function, cardiac rhythm
- Abdominal examination and mid-waist circumference
- Penoscrotal examination
- Rectal examination (if indicated)
177
What tests should be requested when investigating erectile dysfunction?
- Urinalysis (check for infection)
- Fasting blood glucose and lipids
- Total testosterone
- PSA
- Prolactin
- Scan to check blood supply (Rigiscan)
178
What drugs are given to treat erectile dysfunction?
PDE-5 inhibitors, can be given as tablets, injections, suppositories or implants.
179
How do PDE-5 inhibitors work?
Inhibiting cGMP, which would normally inhibit vasodilation. This allows blood flow to the penis.
180
Give two examples of PDE-5 inhibitors
Sildenafil
| Tadalafil
181
What devices can be used to treat erectile dysfunction?
Vacuum-assisted device (requires good vasculature in shaft of penis to be effective)
Implant (reservoir balloon in abdomen, fluid flows from reservoir to penis when button pressed)
182
What sort of cancer is prostate cancer?
Adenocarcinoma (as prostate is a gland)
183
Where does prostate cancer tend to metastasise to?
Lymph nodes and bone (most common)
| Occasionally to lung, liver and brain
184
What tests should be requested for suspected prostate cancer?
Biopsy (definitive)
Serum test: PSA, PSMA (prostate-specific membrane antigen)
Urine test: PCA3, gene fusion products (TMPRSS2-ERG), EN2 protein
185
What is PSA?
Prostate-specific antigen, a serine protease responsible for liquefaction of semen
186
Why would PSA be found in the blood?
Due to retrograde leakage
187
How are PSA levels used to help diagnose prostate cancer?
Elevated PSA level not diagnostic of cancer on its own, can be elevated in BPE, UTI and prostatitis. However, the higher the PSA level, the higher the chance of cancer.
188
What system is used to grade prostate histology specimens based on tissue architecture?
Gleason grading, group 1-5
189
What is TNM staging, with regard to prostate cancer?
```
T = tumour, grade 1-3
T1 = no palpable tumour
T2 = palpable tumour, confined to prostate
T3 = palpable tumour, extending beyond prostate
```
N = nodal (MRI/CT scan)
M = metastatic (bone/PET/MRI scan)
--> Localised/locally advanced/metastatic
190
How is localised prostate cancer treated?
Observation or proceed to curative treatment (surgery, radiotherapy, adjuvant hormone therapy)
191
How is locally advanced prostate cancer treated?
Surgery, radiotherapy and adjuvant hormone therapy
192
How is metastatic prostate cancer treated?
Palliative hormone therapy
193
What are the three types of urinary tract infection?
1. Asymptomatic bacteriuria
2. Uncomplicated
3. Complicated
194
What is pyuria?
The presence of leukocytes in the urine
195
Asymptomatic bacteriuria is always present in which group of patients?
Those who are catheterised
196
What is the difference between complicated and uncomplicated UTI?
Uncomplicated UTI occurs in non-pregnant women
| UTI in any other demographic is considered complicated.
197
Which patients are at particularly high risk of progression of UTI to pyelonephritis?
Renal transplant patients
198
Which pathogen causes >50% of UTIs?
E coli
199
What pathogen that sometimes causes UTI is associated with renal stones?
Proteus (produces urease --> stone formation)
200
What pathogen that sometimes causes UTI is associated with hospital/catheterisation?
Klebsiella
201
What organism can indicate a deep seated infection if found in the urinary tract?
Staph aureus
202
What organism can cause recurrent UTIs and may suggest underlying pathology?
Pseudomonas aeruginosa
203
Why are females more likely to get UTIs?
A shorter urethra means that flora from the bowel are more likely to get in
204
Why is prostate enlargement sometimes associated with UTIs?
Prostate enlargement causes urine stasis
205
What are the main symptoms of a lower UTI?
Frequency
| Dysuria
206
What are the main symptoms of an upper UTI?
Haematuria
| Pyrexia
207
What tests can be used to diagnose UTI?
Urine dipstick
| Microscopy, culture and sensitivities
208
What 7 things does urinalysis look at?
1. Blood
2. Protein
3. pH
4. Glucose
5. Ketones
6. Nitrates
7. Leukocytes
209
What things on urinalysis are seen as evidence of infection?
Presence of leukocytes and protein
210
What are 'casts' seen on urine microscopy?
Formed in renal tubules, may indicate pyelonephritis/glomerulonephritis
211
What does it mean if epithelial cells are seen on urine microscopy?
The specimen was likely poorly taken.
212
Which patients should not be treated if they have asymptomatic bacteriuria?
Those over 65 - these patients are unlikely to develop pyelonephritis and giving antibiotics leads to increased antibiotic resistance.
213
Which antibiotic is normally given as a first line treatment for a UTI?
Nitrofurantoin
214
In which patients is nitrofurantoin contraindicated?
- Patients in 3rd trimester of pregnancy
| - Patients with poor renal function
215
Why is nitrofurantoin generally preferable to trimethoprim?
30% of E coli UTIs are resistant to trimethoprim
216
Which new antibiotics can be given to treat UTIs in the case of resistance to nitrofurantoin?
Fosfomycin
| Pivmecillinam
217
How should UTIs in pregnant women be managed?
- Screening should be offered in pregnancy
- Urine culture rather than dipstick
- Positive cultures should be confirmed with second sample
- Asymptomatic bacteriuria should be treated due to risk of pyelonephritis
- Test of cure should be sent 1 week after treatment
218
What is pyelonephritis?
Infection of the renal parenchyma and soft tissues of renal pelvis/upper ureter
219
Which demographic is most at risk of pyelonephritis?
Women < 35
220
How is pyelonephritis investigated?
Abdominal examination (loin tenderness, renal angle tenderness)
Bloods including cultures
USS to rule out upper tract obstruction
MSU
221
How is pyelonephritis treated?
```
Fluid replacement
IV antibiotics (broad spectrum e.g. co-amoxiclav +/- gentamicin) 7-14 days
Drain obstructed kidney
Catheter
Analgesia
```
222
What are the potential complications of pyelonephritis?
```
Renal abscess (more common in diabetics)
Emphysematous pyelonephritis (rare - gas accumulation in tissues, life threatening, may require nephrectomy)
```
223
Where can urinary stones occur?
Anywhere in the urinary tract - kidneys, ureters, bladder, prostate, urethra
224
Name some congenital factors that can increase the likelihood of developing stones.
Horseshoe kidney
Duplex kidney
Spina bifida
225
Name some acquired anatomical factors that can increase the likelihood of developing stones.
Obstruction
Trauma
Reflux
226
What urinary factors increase the likelihood of developing stones?
- Too much of a particular salt present in the urine (metastable urine)
- Dehydration
- Infection (some UTIs are more commonly associated with infection)
227
In the UK, what are most urinary stones comprised of?
80% are calcium-based
228
What steps can be taken to prevent urinary stones?
```
Adequate hydration
Low sodium diet
Normal dairy intake (low calcium intake does not decrease stone formation)
Moderate protein intake
Maintain normal BMI
Active lifestyle
```
229
What kind of stones can form as a result of congenital disease?
Cystine stones as a result of cystinuria
230
What drugs can be given to treat cystinuria?
Cystine binders:
Captopril
Penicillamine
231
What symptoms do urinary stones typically cause?
May be asymptomatic - many are picked up incidentally
Loin pain
Renal colic (sudden acute severe pain in back/side, which radiates to the lower abdomen, nausea and vomiting)
UTI symptoms (urgency, frequency, dysuria)
Haematuria
232
Why is it a bad idea to drink a lot with urinary stones characterised by renal colic?
The fluid doesn't 'flush' the stone through, it just increases fluid build-up.
233
How should renal colic be investigated?
- ABC
- Give analgesia (diclofenac suppository), antiemetic if required
- Focused history and examination
- Urinalysis (MSU if positive)
- FBC, U&E, calcium, uric acid
- Imaging - non-contrast CT KUB (normal first line)/KUB x-ray (limited use)
234
What are the possible differential diagnoses for presentation with renal colic?
- Vascular accident: assume ruptured abdominal aortic aneurysm until proven otherwise
- Bowel pathology e.g. diverticulitis, appendicitis
- Gynaecological e.g. ectopic pregnancy, ovarian cyst, torsion
- Testicular torsion
- Musculoskeletal issues
235
Why is non-contrast CT preferred to x-ray when investigating urinary stones?
Only 50-60% show up on x-ray, whereas nearly all will show up on CT.
CT also more likely to show other kinds of pathology.
236
What are the problems with CT when investigating stones?
High radiation dose
| Does not give any functional information about the kidneys
237
How is the NCCT KUB interpreted?
1. Count the kidneys - if two are present, can be more relaxed about how one of them is functioning.
2. Condition of the kidneys - perinephric tissues, cortical thickness, hydronephrosis/hydroureter, stones
3. Look for evidence of any other pathology
238
What's the best analgesic to give a patient with ureteric colic if they can't have NSAIDs?
IV paracetamol
239
What is pyonephrosis?
A combination of obstruction and infection - can be rapidly fatal
240
How is pyonephrosis treated?
IV antibiotics
Oxygen
Drainage (nephrostomy/ureteric stent)
241
How would a ureteric stone <5mm normally be managed?
Providing patient is well, with adequate pain control, management normally conservative - give 2 weeks to pass.
242
How would a ureteric stone 5-10mm normally be managed?
ESLW (lithotripsy)
243
How are small renal stones (<1cm) managed?
Conservative management if they are in a safe location, static size and asymptomatic.
244
What are the treatment options for renal stones measuring 1-2cm?
ESWL (extracorporeal shockwave lithotripsy)
| Flexible ureteroscopy with laser
245
What treatment would be used for larger renal stones >2cm?
PCNL (keyhole surgery)
| percutaneous nephrolithotomy
246
How are bladder stones normally treated?
Normally conservative management
Possible endoscopic treatment
Larger stones can be treated via open/laparoscopic surgery
