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Phase 1c: Conditions > Urology and Renal Medicine > Flashcards

Urology and Renal Medicine Flashcards

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1
Q

What is chronic kidney disease?

A

Abnormalities in kidney structure or function present for ≥3 months (GFR <60 mL/minute/1.73 m²) or other markers of kidney damage, e.g. proteinuria

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2
Q

What are the key diagnostic factors of chronic kidney disease?

A

Patients typically asymptomatic until stage 4 or 5 CKD
Fatigue
Oedema (salt and water retention)
Nausea with or without vomiting (accumulation of urea)
Pruritus
Restless legs
Anorexia
Foamy cola-coloured urine
Rashes (ecchymosis and purpura)
Dyspnoea and orthopnoea
Seizures
Hypertensive retinopathy

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3
Q

Apart from GFR, what other evidence suggests CKD?

A

Persistent microalbuminuria
Persistent proteinuria
Persistent haematuria (after exclusion of other causes, e.g. urological disease)
Structural abnormalities of kidney seen on imaging (e.g. polycystic kidney disease, reflux nephropathy)
Biopsy-proven chronic glomerulonephritis

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4
Q

What are the risk factors for CKD?

A

Diabetes mellitus
Hypertension
Age >50 years
Smoking
Obesity
Black or Hispanic ethnicity
Family history
Immune disorders, e.g. SLE, RA
Male sex
Long term use of NSAIDs

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5
Q

How is CKD investigated?

A

U&Es
eGFR
Urinalysis (haematuria and proteinuria)
Urinary albumin
Renal ultrasound (small kidneys, polycystic kidneys)
Kidney biopsy

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6
Q

How is GFR category G1-G2 w/o uraemia treated?

A

ACEi or ARB (ramipril or losartan) - CCB is second line
Dapagliflozin (SGLT2)
Statin (simvastatin)
Consider atenolol, amlodipine, spiranolactone

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7
Q

How is GFR category G5 or with uraemia treated?

A

1st line is dialysis
2nd line is kidney transplant

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8
Q

What are the diagnostic criteria for AKI?

A

Rise in creatinine of ≥ 25 micromol/L in 48 hours
Rise in creatinine of ≥ 50% in 7 days
Urine output of < 0.5ml/kg/hour for > 6 hours

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9
Q

What are the risk factors for AKI?

A

CKD
Heart failure
Diabetes
Liver disease
>65 years
Cognitive impairment
Nephrotoxic medications, e.g. NSAIDs or ACEi
Use of contrast mediums, e.g. CT scans

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10
Q

What are pre-renal causes of AKI?

A

Inadequate blood supply to kidneys reducing the filtration of blood, i.e. due to:
Dehydration
Hypotension (shock)
Heart failure

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11
Q

What are some renal causes of AKI?

A

Intrinsic disease in kidney reduces filtration of blood
Glomerulonephritis
Interstitial nephritis
Acute tubular necrosis

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12
Q

What are some post-renal causes of AKI?

A

Obstruction to the outflow of urine from the kidney, causing back-pressure into the kidney and reduced kidney function
Kidney stones
Masses such as cancer in the abdomen or pelvis
Ureter or uretral strictures
Enlarged prostate or prostate cancer

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13
Q

What are the symptoms of AKI?

A

Nausea or vomiting
Diarrhoea
Dehydration
Decreased urine output
Confusion
Drowsiness
Can often be asymptomatic

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14
Q

How is AKI investigated?

A

Urea and creatinine
Serum potassium (hyperkalaemia is complication of AKI)
Urinalysis
Ultrasound of urinary tract to look for obstruction

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15
Q

How is AKI managed?

A

Treat underlying cause
Fluid rehydration with IV fluids in pre-renal cause
Stop nephrotoxic medications, e.g. ACEi or NSAIDs
Relieve obstruction in post-renal AKI, e.g. with catheter

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16
Q

What are the features of nephrotic syndrome?

A

Low serum albumin (<25g/L)
High urine protein content (foamy urine)
Oedema
Deranged lipid profile (high cholesterol, triglycerides, LDLs)
High blood pressure
Hyper-coagulability
MOST COMMONLY SEEN IN 2-5 YEAR OLDS

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17
Q

What are the causes of nephrotic syndrome?

A

Minimal change disease (most common cause)
Intrinsic kidney disease (membranoproliferative glomerulonephritis, focal segmental glomerulosclerosis)
Secondary to underlying illness (diabetes, henoch schonlein purpura, infection - HIV, hepatitis, malaria)

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18
Q

How is minimal change disease diagnosed?

A

Urinalysis (small molecular weight proteins and hyaline casts)
Serum albumin (low)
Serum lipid profile (high cholesterol)
Urine dipstick (proteinuria)
Renal biopsy (for steroid-resistant patients)

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19
Q

How is nephrotic syndrome managed?

A

High dose steroids (prednisolone) - given for 4 weeks and gradually weaned over 8 weeks
ACEi (ramipril) and immunosuppressants (cyclosporine, rituximab) in steroid-resistant children
Low salt diet
Diuretics to treat oedema (furosemide)
Albumin infusions in severe hypoalbuminaemia
Antibiotic prophylaxis in severe cases
Prophylactic anticoagulation (low molecular weight heparin or warfarin)

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20
Q

What are complications of nephrotic syndrome?

A

Hypovolaemia
Thrombosis (anti-clotting factors lost in kidneys, liver produces pro-thrombotic factors in response to low albumin)
Infections (kidneys leak immunoglobulins)
Acute or chronic renal failure
Relapse

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21
Q

What is testicular torsion?

A

Twisting of the spermatic cord resulting in constriction of vascular supply and ischemia of testicular tissue

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22
Q

What are the risk factors for testicular torsion?

A

Age <25 years
Bell clapper deformity (allows testicles to rotate freely within tunica vaginalis)

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23
Q

What are the symptoms of testicular torsion?

A

Acute onset of unilateral testicular pain - trigger such as playing sports
Abdominal pain and vomiting
Firm swollen testicle (oedema)
Elevated testicle - no pain relief upon elevation of scrotum
Absent cremasteric reflex
Abnormal testicular lie (often horizontal)
Rotation, so that epididymis is not in normal posterior position
USUALLY TEENAGE BOYS

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24
Q

How is testicular torsion investigated?

A

Scrotal ultrasound (whirlpool sign) - will delay treatment, but confirms diagnosis
Surgical exploration is first line

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25
How is testicular torsion treated?
Bilateral orchiopexy (correcting the position of the testicles and fixing them in place) Orchidectomy (removing the testicle) if the surgery is delayed or there is necrosis
26
What are the symptoms of benign prostatic hyperplasia?
Storage symptoms: frequency, urgency, nocturia Voiding symptoms: weak stream, hesitancy, intermittency, straining, incomplete emptying, post-void dribbling
27
What are the risk factors for BPH?
Age >50 years Family history
28
How is BPH investigated?
DRE (assess size, shape and characteristics of prostate) Urinalysis (normal in uncomplicated BPH, may show UTI, haematuria suggests bladder cancer) PSA (false positives and negatives high) Urinary frequency volume chart (show fluid intake and output)
29
What are some causes of raised PSA?
Prostate cancer BPH Prostatitis UTIs Vigorous exercise (particularly cycling) Recent ejaculation or prostate stimulation
30
How is BPH treated?
Alpha-blockers (tamsulosin) - relaxes smooth muscle (symptom control) 5-alpha reductase inhibitors (finasteride) - reduces size of prostate Transurethral resection of prostate (TURP) Transurethral electrovaporisation of the prostate (TEVAP/TUVP) Holmium laser enucleation of the prostate (HoLEP) Open prostatectomy via an abdominal or perineal incision
31
What are the side effects of tamsulosin?
Postural hypotension
32
What are the side effects of finasteride?
Sexual dysfunction (decreased testosterone)
33
What are the symptoms of a lower UTI?
Dysuria (pain or burning when passing urine) Suprapubic pain or tenderness Increased frequency and urgency Incontinence Cloudy-looking urine Confusion is commonly the only symptom in older patients
34
What are the symptoms of pyelonephritis?
Fever Loin, suprapubic or back pain Malaise Vomiting Loss of appetite Haematuria
35
What are the risk factors for UTIs?
Sexual activity Spermicide use Post-menopause Catheter History of recurrent UTIs
36
How is UTI investigated?
Urine dipstick Urine culture and sensitivity if nitrites and leukocytes present
37
What are the causative organisms of bacteria?
E. coli (most common) Klebsiella pneumoniae Enterococcus Pseudomonas aeruginosa
38
How are simple UTIs managed?
Trimethoprim (avoided in first trimester of pregnancy and if mother on anti-epileptics) Nitrofurantoin (avoided in third trimester of pregnancy)
39
How long are antibiotics given for UTIs?
3 days for simple UTI in women 5-10 days of antibiotics for women that are immunosuppressed, have abnormal anatomy or impaired kidney function 7 days of antibiotics for men, pregnant women or catheter related UTIs
40
How is pyelonephritis treated?
7-10 days of cefalexin OR co-amoxiclav OR trimethoprim
41
What are the risk factors for bladder cancer?
Tobacco exposure; MESOTHELIOMA Male sex Age >55 years Exposure to chemical carcinogens - aromatic amines (dye and rubber); TRANSITIONAL CELL CARCINOMA Pelvic radiation Systemic chemotherapy Schistosomiasis; SQUAMOUS CELL CARCINOMA Family history
42
What are the symptoms of bladder cancer?
Painless haematuria (gross or microscopic) Dysuria (painful urination) Recurrent UTIs or lower urinary tract symptoms
43
How is bladder cancer investigated?
Urinalysis (haematuria present in 80% of patients) - 1st line Cystoscopy and biopsy - gold standard
44
How is bladder cancer treated?
DEPENDENT ON DISEASE STAGING Carcinoma in-situ: resection via TURBT Muscle-invasive bladder cancer: radical cystectomy, ileal conduit formation/bladder reconstruction Metastatic disease: chemotherapy (cisplatin-based regime)
45
What are the risk factors for epididymitis?
Multiple sexual partners - most commonly caused by sexually transmitted pathogens Bladder outflow obstruction Cystopic procedures and catheterisation Immunosuppression Age >19 years
46
How does epididymitis present?
Unilateral, gradual onset (minutes-hours) Testicular pain and swelling Tenderness on palpation Urethral discharge (gonorrhoea or chlamydia) Systemic symptoms, e.g. fever, sepsis
47
How is epididymitis investigated?
in younger adults, test for STIs with NAAT in older adults, midstream sample of urine surgical exploration if testicular torsion not excluded
48
What organisms commonly cause epidymitis?
Age <35 years: Chlamydia trachomatis, Neisseria gonorrhoea Age >35 years: E. coli, Klebsiella
49
How is epididymitis managed?
Conservative: bed rest, scrotal elevation Medical: analgesia, antibiotics
50
What antibiotics are given for enteric epididymitis?
Ofloxacin for 14 days Levofloxacin for 10 days Co-amoxiclav for 10 days (where quinolones are contraindicated)
51
What antibiotics are given for sexually transmitted epididymitis?
Intramuscular ceftriaxone (single dose) Doxycycline Ofloxacin
52
What are the types of kidney stones?
Calcium oxolate (most common) Calcium phosphate Uric acid Struvite (associated with infection, produced by bacteria) Cystine (semi-opaque, ground glass appearance) Xanthine (radio-lucent)
53
What are the symptoms of kidney stones?
May be asymptomatic until they get stuck in the ureters Renal colic (unilateral colicky loin to groin pain) Haematuria Nausea or vomiting Reduced urine output Symptoms of sepsis, if infection is present
54
How are kidney stones investigated?
Urine dipstick (haematuria, excludes infection) U&Es (hypercalcaemia as cause?) Non-contrast CT KUB Renal ultrasound in pregnant women and children
55
What are some causes of hypercalcaemia?
Calcium supplementation Hyperparathyroidism Cancer
56
What are the complications of kidney stones?
Obstruction leading to acute kidney injury Infection with obstructive pyelonephritis
57
How are kidney stones treated?
NSAIDs (IM diclofenac) Antiemetics (metoclopramide) Antibiotics if infection present Tamsulosin (alpha-blocker) - may aid passage of stones Surgical intervention if stone >10mm If there is ureteric obstruction with infection, surgical decompression
58
What surgical interventions are used for kidney stones?
Extracorporeal shock wave lithotripsy (ESWL) - stone <2cm in aggregate Ureteroscopy - stone <2cm in pregnant females Percutaneous nephrolithotomy (PCNL) - complex renal calculi and staghorn calculi Open surgery
59
What are the risk factors for prostate cancer?
Increasing age Obesity Afro-Caribbean ethnicity FHx
60
What is the most common form of prostate cancer?
Adenocarcinoma
61
What are the symptoms of prostate cancer?
May be asymptomatic Lower urinary tract symptoms: hesitancy, urinary retention, weak flow, terminal dribbling Haematuria Erectile dysfunction Weight loss, back pain
62
How is prostate cancer investigated?
DRE: hard, asymmetrical, craggy, irregular prostate Multiparametric MRI (1st line) Prostate biopsy - transrectaul ultrasound-guided biopsy (TRUS) or transperineal biopsy PSA (can be falsely raised)
63
How is prostate cancer assessed?
Gleason score 6 is considered low risk 7 is intermediate risk (3 + 4 is lower risk than 4 + 3) 8 or above is deemed to be high risk
64
How is prostate cancer managed?
Low risk disease: active surveillance Intermediate and high risk: radical prostatectomy or radiotherapy Metastatic disease: anti-androgen therapy, e.g. Goserelin
65
What are the risk factors for testicular cancer?
Undescended testes Male infertility Family history Increased height
66
What are the symptoms of testicular cancer?
Painless lump - non-tender, hard, irregular, non-fluctuant Gynaecomastia Hydrocoele Will spread to para-aortic lymph nodes
67
How is testicular cancer investigated?
Scrotal ultrasound Alpha-fetoprotein (raised in teratomas, not seminomas) Beta-hCG (raised in both teratomas and seminomas) - only 10% of seminomas LDH (non-specific tumour marker) Staging CT
68
What are the side effects of GnRH agonists?
Can cause a paradoxical increase in prostate cancer symptoms - inital rise in testosterone due to overstimulation of LH Therefore, anti-androgen is given alongside
69
How is testicular cancer managed?
Surgery (radical orchidectomy) Chemotherapy Radiotherapy Sperm banking
70
what are the complications of TURP?
TURP syndrome: mental confusion, vomiting, hypertension and bradycardia urethral stricture/UTI retrograde ejaculation perforation of the prostate
71
what are the main complications of urethral bladder catheterization?
UTI (particularly Proteus mirabilis) urethral trauma, inc. creation of false passage urethral scarring and stricture bladder perforation
72
what are the examination findings of a varicocoele?
throbbing/dull pain on standing dragging sensation subfertility scrotal mass - feels like a 'bag of worms' more prominent on standing, disappears when lying down - if not, ?retroperitoneal tumour

Phase 1c: Conditions (18 decks)

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