Urology - general Flashcards
Define AKI
- Urine output is <0.5ml/kg/h for >6 consecutive hours
- Serum creatinine rises by >26.4 μmol/L within 48h
- Serum creatinine rises >1.5x from the reference value known to have occurred within one week/ 50% or greater serum creatinine rise in the preceding 7 days
- > 25% fall in eGFR in children + young people within the past 7 days
Pre-renal causes of AKI
- Hypotension (intravascular volume loss or redistribution)
- Hypovolaemia (extracellular volume loss)- Reduced effective arterial volume
- HF, protein losing encephalopathy (decreased CO)
- Drugs
- ACEi, NSAIDs, ARB, diuretics
Interstitial nephritis (renal AKI)
- secondary to NSAIDs, chronic frusemide use
- caused by - infections, drugs, immune diseases e.g. SLE, lymphoma, tumour lysis syndrome following chemo
Renal causes of AKI
- Tubular disease
- acute tubular necrosis (post-ischaemic. nephrotoxic)
- Glomerular disease
- Interstitial disease
Palpable kidneys
- Polycystic kidney disease
- Hydronephrosis
Renal angle tenderness
- Renal colic
- Pyelonephritis
- Any other pathology that stretches the renal capsule
Classification of CKD (5)
eGFR (ml/min) >90 kidney damage with preserved GFR e.g. proteinuria
60-90 kidney damage with mild renal impairment
30-59 moderate renal impairment
15-29 severe renal impairment
<15 end-stage renal failure
Normal GFR is 90ml/min
Normal Urea value
2.5-7.1 mmol/L
Normal Creatinine value
79-118 μmol/L
Nephrotic syndrome
- Proteinuria (>3.5/24h)
- Hypoalbuminaemia (<30g/L)
- Oedema(+hyperlipidaemia)
Increased risk of infection - loss of complement + Ig in urine
Hypercoaguable state - loss of ATIII, hypogammaglobulaemia
Nephritic syndrome
- Haematuria (sometimes macroscopic) – MAIN FEATURE
- HTN
- Sub-nephrotic-range proteinuria
Nephrotic range proteinuria
Commonest causes in Children Young adults Older people Diabetics
Children + young adults - minimal change glomerulonephritis
Young adults - FSGC (focal segmental glomerulosclerosis)
Older people - membranous nephropathy
Diabetics - diabetic nephropathy
Places where a renal calculus can get suck
Staghorn calculus - in kidney, non-mobile, no pain, incidental finding
Pelviureteric junction
Ureteric stone - pelvic brim
Vesicoureteric junction
Complications of kidneys stones
- Ureteric stricture
- Infection
- Acute/chronic pyelonephritis
- Renal failure
- Intrarenal/periephric abscess (renal mass with fluid level on US - pus discharges through the renal capsule in the perinephric fat)
- Xanthogranulomatus pyelonephritis
- Urine extravasation into pelvic cavity
Patients with PKD are at risk of
SAH
Complications of chronic urinary retention (8)
- UTI
- Incontinence
- Bladder Stones
- Hydroureters/hydronephorsis
- Renal failure
- Acute-on-chronic retention
- Bladder wall hypertrophy (trabeculation)
- Bladder wall outpouchings (diverticula)
Conditions that can lead to acute renal failure (5)
- Wegener’s granulomatosis
- Goodpasture’s syndrome
- Thrombotic thrombocytopenic purpura (TTP) - pentad of TTP
Thrombocytopenia
Microangiopathic haemolytic anaemia (MAHA)
Fever
Renal failure
Neurological symptoms - HUS
- Myeloma
- Retroperitoneal fibrosis
Which part of the prostate is affected in BPH (definition of BPH)
slowly progressive nodular hyperplasia of the TRANSITIONAL (periurethral) zone of the prostate gland
It’s a histological diagnosis
What kind of cancers are prostate cancers?
malignant tumour of glandular origin situated in the prostate
most are adenocarcinomas arising in the PERIPHERAL zone of the prostate gland
All testicular tumours display an abnormality on Chr
12
Which testiular cells are the most vulnerable to ischaemia?
Germ cells
Which testis gets twisted most commonly?
Left
Direct vs indirect inguinal hernia
Direct
Superior and medial to pubic tubercle
Through the abdominal wall
Medial to deep inferior epigastric artery
Through Hesselbach’s triangle
Doesn’t usually extend into scrotum
Cough impulse - will expand outwards (through the defect in the posterior wall of the inguinal canal)
Lower risk of strangulation than indirect hernias
greater tendency for spontaneous reduction
Indirect
More common than direct
Superior and medial to pubic tubercle
Through the deep inguinal ring
Lateral to deep inferior epigastric artery
lateral to Hesselbach’s triangle
More likely to extend into scrotum
Cough impulse - will expand in an inferomedial direction (along the length of the inguinal canal)
Higher risk of strangulation than direct hernias
deep inferior epigastric artery lies medial to the deep inguinal ring
Inguinal vs femoral hernia
Inguinal
Superior and medial to pubic tubercle
Still more common in F than femoral
Femoral
Inferior and lateral to pubic tubercle
F>M
Higher risk of stangulation than inguinal because it has a narrower neck
How to distinguish between a direct and an indirect inguinal hernia
Reduce the hernia and put your hand over the deep inguinal ring
Get patient to cough - if the hernia reappears then it means it is direct (through the abdominal wall)
if it doesnt reappear it means it’s indirect (through the deep inguinal ring which you are blocking with your hands)
deep inguinal ring:
• Midpoint of inguinal ligament
• 1.5cm above midpoint
• Opening in transversalis fascia
First line ix for any scrotal mass
USS testis
What will intermittent episodes of obstruction make you worry of?
Hernia
What is radical orchidectomy performed for and how is it performed?
• Radical orchidectomy done to remove testicular cancer
Performed via an inguinal incision rather than a scrotal incision
o Lymph node supply of scrotal skin is different to that of the inguinal cord + the testicle - you don’t want to spread cancer cells from one compartment (where the testicle drains) to the other (where the scrotal skin drains)
testis - para-aortic
scrotum - inguinal
Commonest type of testicular tumour in
20-30 y/o
30-50 y/o
20-30 - teratoma
30-50 - seminoma
On which testes are varices most common?
Left
o R gonadal vein drains directly into IVC at an oblique angle
o L gonadal vein drains into L renal vein at a 90o angle
What does a sudden appearance of L sided varix make you worry of?
Renal tumour compressing the L renal vein and compromising the drainage of the L gonadal vein
Commonest causes of epidydimo-orchitis in
Men <35
Men >35
o Men <35 y/o - STIs (consider Chlamydia trachomatis (most common), Neisseria gonorrhoeae)
o Men >35 y/o - UTIs (e.g. Escherichia Coli, Enterobacter, Klebsiella)
o Anal intercourse - increases risk of epididymo-orchitis due to exposure to coliforms
o Others - mumps, Candida
Describe idiopathic scrotal oedema
Acute onset Bilateral Extends into the groin Not painful Resolves over 48-72h Needs no further management
(testicular torsion, epididymo-orchitis - would all result in pain)
Relative positions of the femoral nerve, artery, vein in the inguinal region
Medial to lateral - VAN
Why are smokers more likely to develop hernias and suffer hernia recurrence?
Impaired connective tissue metabolism causing abdominal wall weakness
