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Y3 Charis > Urology - mx > Flashcards

Urology - mx Flashcards

1
Q

Urethral stricture management options

A

Cystoscopy to visualise the urethral stricture and then

  • Dilation
  • Urethral stent
  • Cystoscopic urethrotomy
  • Surgery to remove the affected portion
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2
Q

Indications for urgent dialysis

A
  • eGFR <10ml/min + benefits outweigh risks
  • eGFR <6ml/min + no reversible features
  • Life-threatening complications
  • Hyperkalaemia (>6.5mM)
  • High creatinine (>1000μM)
  • Hyperuricaemia (>300mM)
  • Symptoms or complications of uraemia (e.g. pericarditis)
  • Uraemic encephalopathy
  • Fluid overload (severe pulmonary oedema)
  • Severe acidosis (pH <7.2) refractory to medical management
  • Drug overdose by BLAST drugs – Barbiturates, Lithium, Alcohol, Salicylates, Theophyline
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3
Q

Complications of bladder catheterisation

A
  • UTI (proteus mirabilis) - dysuria, confusion, pyleonephrtis
  • Urethral trauma - pain, bleeding
  • Urethral scarring + Stricture - slow-flowing micturition, dysuria, urinary retention
  • Creation of false passage in the urethra - pain, infection
  • Bladder perforation - pain, bleeding, peritonitis
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4
Q

Incontinence management

A
  • Anti-muscarinics (tolterodine, oxybutynin)

PNS - pelvic nerve + Ach receptors –> stimulate contraction of detrusor muscle

SNS - hypogastric nerve + NA receptors –> inhibit contraction of detrusor muscle

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5
Q

To alleviate outflow obstruction

A
  • A adrenergic blockers (doxazosin, prazosin, tamsulosin, afluzosin)
    Act on a receptors + block contraction of internal urethral sphincter + SM of prostate capsule
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6
Q

AKI Mx

A
  • Asses volume status + aim for euvolaemia
    If pt is dehydrated, stop diuretics
    Match daily input to loss + 500ml for insensible loss but more if pyrexic
  • Withhold drugs that reduce eGFR
  • Withhold nephrotoxic drugs (ACEi, ARBs, gentamicin)
  • Withhold/reduce drugs that are renally excreted (e.g. metformn if eGFR <30, sulphonylureas, insulin, co-amoxiclav)
  • Adequate nutrition
  • If using contrast, hydrate patient pre- + post-contrast
  • BP control
  • Treat the underlying cause
    Pre-renal: Correct volume depletion with appropriate fluids, antibiotics (IF sepsis), inotropes (norepinephrine, dobutamine, IF signs of shock)
    Post-renal: Catheterise + imaging of renal tract (CTKUB) + urology + reversal
    Intrinsic renal: Refer early to nephrology
- Manage complications 
   Hyperkalaemia 
   Pulmonary oedema 
   Uraemia 
   Acidemia

Renal replacement therapy – haemodialysis and haemofiltration if any complications are refractory to medical Mx

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7
Q

Pre-renal azotaemia (high levels of nitrogen compounds in the blood) mx

A
  • IVF +/- blood transfusionIn intrinsic renal failure, if there is pre-existing pre-renal azotaemia, treat with volume expansion
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8
Q

Indications for renal replacement therapy (haemodialysis, haemofiltration)

A

If renal function does not improve

  • Uraemia
  • Severe metabolic acidosis
  • Hyperkalaemia refractory to medical management (>6.5 mM)
  • Volume overload unresponsive to diuretics
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9
Q

Supportive management in patients with AKI

A
  • Intensive control of their a) fluid balance, b) electrolytes
  • Oxygenation
  • Nutrition
  • Glycaemic control
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10
Q

Management of the 6 complications of AKI

A

Hyperkalaemia** (K+ >6.5mM)
- 10ml 10% IV calcium gluconate/IV calcium
- Calcium resonium
- 10 U actrapid (insulin) + 50ml 50% glucose
or
5U actrapid + 100ml 20% dextrose
- Nebulsied salbutamol

    • In an emergency
  • Salbutamol nebulisers
  • Insulin and dextrose –> They activate the co-transporters on cells which move potassium back into cells and lowers serum potassium for 30-45 minutes

Other answers are used in the treatment of hyperkalaemia but not during emergencies

Hyperphosphatemia (ectopic calcification, secondary hyperparathyroidism, renal osteodystrophy)

  • Dietary restriction
  • Adminisration of phosphate binders (calcium acetate, calcium carbonate, sevelamer, lanthanum carbonate)
  • DialysisPulmonary oedema (hypoxia, hypercapnia, acidosis, SOB)
  • Sit up + High-flow O2
  • Diuretics - IV furosemide
  • Nitrates
  • Opiates - diamoprhine 2.5mg IV + cyclizine 50mg
  • Non-invasive positive pressure ventilation
  • Renal replacement therapy if a) unresponsive to diuretics, b) absence of a reasonable urinary output

Fluid-overload

  • Diuretics (careful not to dehydrate patient + give them a pre-renal AKI)
  • Renal replacement therapy if unresponsive to diuretics

Acidosis

  • Often improves with management of hyperkalaemia
  • Sodium bicarbonate 50-100ml of 8.4% IV sodium bicarbonate

Uraemia (pericarditis, encephalopathy, uraemic frost, twitching, hiccups, lethargy, confusion)
- Dialysis

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11
Q

Proteinuria mx

A
  • Control oedema - diuretics, low salt diet
  • AT II blockade
  • ACEi, ARB
    ACEi contraindicated in renal artery stenosis
  • Treat cause - immunosuppresion/steroids may be needed
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12
Q

Rhabdomyolysis mx

A

Fluid resuscitation

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13
Q

Immediate urolithiasis management (immediate + general advice)

A

Immediate

  • ABC
  • IVF (vomiting - dehydration)
  • Multimodal analgesia (paracetamol + PR diclofenac, may need opioids)

General advice

  • Increase fluid intake
  • avoid red/brown foods - contain oxalic acid that increases stone formation
  • Do not cut out dairy products - milk binds to oxalate
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14
Q

Definitive urolithiasis management

kidney stones

A

Stone <5 mm - allow to pass spontaneously
*Infection - abx, nephrostomy to help drain the kidney
*Obstruction - stent
*No infection/obstruction - conservative management, analgesia + medication to relax the ureters and help them pass the stones
Tamsulosin - a-blocker (superior to nifedipine)
Nifedipine - CCB
* Potassium citrate for uric acid stones
Alkalises urine + dissolves stones + inhibits formation of crystals

Stone >5mm - surgery
*Infection - abx, nephrostomy to help drain the kidney
*Obstruction - stent, precutaneous nephrolithotomy
*No infection/obstruction
ESWL (extracorporeal shock wave lithotripsy) - if small (renal stone <2cm, ureteric stone <1cm)
Flexible URS (ureteronoscopy) removal/Uteroscopic lithotripsy - if too large/contraindcations for ESWL, if patient obese or pregnant
Precutanous nephrolithotomy (PCNL) - third line after ESWL, URS used for large stones (>2cm) staghorn calculi, cysteine stones
Stenting (JJ stent)/precutaneous nephrostomy - if obstruction can’t be resolved surgically, to prevent hydronephrosis
Laparoscopic/open surgery - if ESWL, URS, PCNL fail

EMERGENCY - any signs or an obstructed + infected kidney –> urgent nephrostomy to relieve the obstruction

Abx cover given if any invasive procedure is employed

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15
Q

Causes + Management of

Calcium oxalate + Calcium phosphate stones

A
  • Hypercalciuria - exclude hyperparathyroidism, low-calcium diet
  • Hyperuricosuria - allopurinol (inhibits production of uric acid during breakdown of nucleic acids)
  • Hypocitraturia - potassium citrate (alkalises urine and inhibits crystal formation)
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16
Q

Causes + Management of Uric acid stones

radiolucent
the only type of kidney stones that dissolves

A
  • Hyperuricaemia
  • Gout
  • Potassium citrate (alkalizes urine + prevents crystal formation, dissolves stone)
  • Allopurinol
17
Q

Causes + Management of Struvite/ MAP (magnsium ammonium phosphate stones)

A

2y to infections w urease producing bacterium/ammonia producing organism (break down urea into ammonium)

Most common bacteria: Proteus, pseudomonas, Klebsiella
Treatment of underlying infection

18
Q

Causes + management of cysteine stones

A

-Cystinuria (AR w increased cysteine excretion)

  • Increase fluid intake
  • Potassium citrate
  • Cysteine binding drugs given if all else fails (e.g. tiopronin)
19
Q

5 situations in which patients with urolithiasis will need to be admitted

A
  • Evidence of UTI
    Infection proximal to obstruction is a medical emergency and needs surgical drainage
  • Evidence of renal impairment/failure - raised U, Cr, K
  • Refractory pain despite analgesia
  • Bilateral obstructing stones/single obstructing stone when 1 kidney present
  • Elderly/young/unwell
20
Q

Surviving sepsis guidelines

A
  • IVF
  • O2
  • Analgesia
  • Abx
  • Blood cultures
  • VBG
  • Assess renal function
  • Watch out for intrarenal/perinephric abscess
21
Q

TURP complications (7)

A
  • TURP syndrome
  • Urethral stricture
  • UTI
  • Incontinence
  • Haemorrhage
  • Retrograde ejaculation
  • Erectile dysfunction
22
Q

UTI during pregnancy

Which abx to use?

A

Ok to use

  • Penicillins + Cephalosporins (e.g. cephalexin)
  • Nitrofurantoins

Not ok to use

  • Trimethoprim - folic acid antagonist
  • Fluoroquinolones + tetracyclines - teratogenic
  • Ampicillin - no longer used because of increased resistance

Vancomycin can also be used but it has to be given IV and is suitable for gram +ve cover, whereas most of the UTIs are caused by gram -ve bacteria (E.coli)

23
Q

UTI management

a) Females, uncomplicated
b) Females, complicated
c) Males

A

a) Nitrofurantoin/Trimethroprim
b) Ciprofloxacin (outpatient)
IV gentamicin
(inpatient - Considered for women with fever, increased WCC, emesis, volume depletion in addition to UTI symptoms )

c) TrimethorpimNitrofurantoin (2y option)
b) complicated means not just urological symptoms –> patient is confused, complaints of generalised loin pain, has a temperature

24
Q

BPH mx

A
  • Emergency – Acute urinary retention – catheterisation
  • Conservative – watchful waiting + reduce evening fluid intake

• Medical
o Selective α-blockers (e.g. tamsulosin, alfuzosin) – relax the smooth muscle of the internal urinary sphincter + prostate capsule
o 5α- reductase inhibitors (e.g. finasteride, dutasteride) – inhibit conversion of testosterone to dihydrotestosterone  can reduce prostate size by about 20% (work in larger prostates, >30g/ml/cc (cubic centimeters) or PSA >1.4ng/ml)
o PDE-5 inhibitor (phosphodiesterase-5) (e.g. sildenafil/Viagra) – considered for pt with BPH + erectile dysfunction
o Anti-cholinergic agent (e.g. tolterodine) – helps storage/irritative symptoms

• Surgery
o TURP

o Open prostatectomy

o Alternatives
 Laser surgery – mutilating (cut the whole lobe out) or ablative (vaporise a bit of the prostate to create a channel)
 Rezum/steam – causes prostate tissue to boil + atrophy
 Urolift – staples in prostate to staple it to one side + create a channel
 Embolization – cuts off the blood supply
 Catheter options

25
Q

Management of overactive bladder/incontinence

A

• Management of overactive bladder (management of storage symptoms caused by overactive detrusor muscle)
o Conservative management – reassure, dietary advice (caffeine, citrus fruit can really irritate the bladder), bladder retraining exercises
o Medical management – anticholinergics (e.g. tolterodine, oxybutinin, detrusitol, solifenacin), β-agonists (betmiga)
o Surgical management – intravesical Botox injection

26
Q

Testicular cancer mx

A

• Radical R/L orchidectomy
• Radical orchidectomy performed via an inguinal incision rather than a scrotal incision
o Removing malignant testes through scrotal incision - risk of seeding malignant cells into scrotum during the procedure
o Lymph node supply of scrotal skin (inguinal nodes) is different to that of the inguinal cord + the testicle (para-aortic nodes) you don’t want to spread cancer cells from one compartment (where the testicle drains) to the other (where the scrotal skin drains)

• Collect sperm prior to procedure – safeguard against reduction in fertility after surgery/radiotherapy

  • Seminomas highly radiosensitive
  • Teratomas are not radiosensitive

• Post-op – surveillance +/- chemo +/- radio +/- RPLND (retroperitoneal lymph node dissection)

• Seminoma
o Chemotherapy (carboplatin) post orchiectomy
o External beam radiation post-orchidectomy

• Teratoma
o RPLND post-orchidectomy
o Chemotherapy post-orchidectomy

• Advanced cancer/metastasis
o Combination chemotherapy post-orchidectomy
following orchidectomy seminomas with metastases are treated using chemo

27
Q

Testicular torsion mx

A

• Do not delay surgery (90% of rescuing tests at 6h, 5% at 24h, testicular necrosis >24h)
o Emergency scrotal exploration + operative repair within 6h of the onset of symptoms
o If there is delay in reaching theatre - attempt manual de-rotation of the testis (outwards rotation)

o Bilateral orchidopexy - suturing the testicle to the scrotal tissue to prevent recurrence
o If testicle is necrotic - orchidectomy

• Supportive care
o Analgesia (morphine sulfate)
o Anti-emetics (ondansetron)

28
Q

Urinary incontinence mx

A

o Conservative management – reassure, dietary advice (caffeine, citrus fruit can really irritate the bladder), bladder retraining exercises

o Medical management
Anticholinergics (e.g. tolterodine, oxybutinin, detrusitol, solifenacin)
β-agonists (betmiga)

o Surgical management – intravesical Botox injection

29
Q

Epidydimo-orchitis mx

A

• Bacterial infection
o Gonorrhoea/Chlamydia – ceftriaxone + doxycycline
o Gonorrhoea/Chlamydia/enteric organisms – ceftriaxone + ofloxacin/levofloxacin
o Enteric organisms – ofloxacin/levofloxacin
o Mycoplasma genitalium – moxifloxacin
o NSAIDs/paracetamol

• Idiopathic/viral
o NSAIDs/Paracetamol

• TB
o Treat with systemic abx to local guidelines (highly variable TB strains + abx resistance patterns)

• Severe epididymo-orchitis w features of bacteraemia
– IVF
– Electrolyte imbalance correction
– IV broad-spectrum abx (cefuroxime)

30
Q

CKD management

A

1) Limit progression/complications
BP: target <130/80 ( <125/75 is diabetic)
Tight glucose control in DM
Decrease CVS risk ( stop smoking, lose weight etc)
Diet: moderate protein, restrict K+, avoid high phosphate foods
Renal osteodystrophy:
- Calcichew - Ca supplement
- Calcium acetate - phosphate binders
- Cinacalcet (calcimimetic) – reduce PTH levels

Symptom control

  • Anaemia: Human EPO might be required
  • Acidosis: Consider sodium bicarbonate supplements for patients with low serum bicarbonate.
  • Oedema: loop diuretics, restriction of fluids
31
Q

CKD mx

A

Education + lifestyle

BP control
Aim for <140/80
DM w ACR >70 - <130/80
ACEi/ARB if ACR>70, ACR >30 + HTN, ACR >3 + DM

Statins
Offer to all w CKD
Atorvastatin 20mg

Immunisations

32
Q

Name 2 potassium sparring diuretics

A

Spironolactone

Amiloride

33
Q

First line mx for nephrotic syndrome

A

Fluid restriction
Diuretics
Consider Prophylactic anticoagulation + discourage bed rest (hypercoaguable state)

Y3 Charis (35 decks)

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