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122 Cards in this Set
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What is renal artery stenosis
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This is where the blood supply to the kidney is affected.
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What are the two main causes of renal artery stenosis
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The major cause of renal artery stenosis is where the narrowing of the arteries is caused by atherosclerosis. The other cause which you should think about is Fibromuscular Dysplasia. This should be suspected in the younger patients. It is where we have fibrous tissue getting layed down in the blood vessel, which then narrows the lumen.
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What are the clinical features of renal artery stenosis
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The clinical features patients will get is firstly hypertension which is triggered by the RAAS as the kidney has ischemia and reduced flow. Clues may be found if giving the patient anti hypertensives is reducing the kidney function. Some patents due to the fluid overload can get a pulmonary oedema which has an acute onset. This is called flash pulmonary oedema. The echocardiogram would often show the left ventricle being normal shaped and thus not the cause of the oedema.
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What are the examination findings in renal artery stenosis
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On examination you may hear bruits at points where atheroscelrosis affects such as the carotids, and abdominally.
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What investigations should be carried out in renal artery stenosis
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The investigations are basically doing an ultrasound, this is because if only one kidney is affected, with a lack of blood supply to it, the size can get reduced. In addition a Doppler ultrasound can be used to look at the flow of the blood in the artery. A CT angiography is the diagnostic test however.
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What is the management of renal artery stenosis
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Treament is by dilating the vessels with transluminal angioplasty, and sometimes a stent is placed in the artery.
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Describe renal cell carcinoma
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A renal cell carcinoma is a tumour which will occur of the tubular cells of the nephron. They are often pathologically called Adenocarcinomas. The most common group of people this affects is males and smokers. The most logical reason that it effects males more is probably because they smoke more than women. There also is a genetic link. It appears to be more common in patients who suffer from Von Hippel-Lindau syndrome. This is where there is a deletion of a tumour suppresor gene.
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What is the clinical presentation of renal cell carcinoma
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The clinical presentation of tumours in the kidney may just be found as an incedental finding on a scan, as most will just remain asymptomatic. However sometimes symptoms can develop. There is a core triad of symptoms. There can be bleeding and thus haematuria. This is from the cancer growning and destroying tissues and blood vessels. Some patients may complain of loin pain as the tumour grows it stretches the kidney. Whilst some may just have a mass. There can also be simple systemtic problems lso associated due to the release of cytokines from the tumour such as fever, weight loss, fatigue and tierdness.
The tumour is responsible for also secreting certain hormones. Therefore this cancer is involved with paraneoplastic syndromes. This can release PTH related peptide, thus Hypercalcaemia can result. EPO can get secreted more leading to polycythemia. Also renin has been reported and this can lead to hypertension. This cancer is also capable of Metastasing. |
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What are the investigations and management of renal cell carcinoma
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An ultraosund can show the mass. A CT of the abdomen is required to stage it. Management involves surgery to remove the mass. This can be done via a radical nephrectomy which is where the kidney and surrounding tissue such as lymph nodes are also removed. Alterantively you can do a percutanoeus radio frequency ablation which is where probe placed near the area and heat used to destroy the tumour
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What is an Oncocytoma
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This is the other tumour which can arise from the kidneys. This is one which is benign and tends to come from the collecting ducts. It is important to consdier this because this will also present with a mass.
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Describe the normal histology of the bladder wall
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The histology of the bladder wall is that there are three layers. The most inner layer is called the Uroepithelium, this is where we have a transitional cell epithelium. What this means is that there are just a number of cells that are lined up ontop of one another, and this layer is capable of being stretched as the bladder fills. These cells are ontop of a basement membrane. Underneath this is the lamina propria containg blood vessels and nerves. The third layer is the smooth muscle, which is called the detursor muscle.
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What are the risk factors for bladder cancer
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The risk factors for developing cancer of the bladder is people who smoke and also exposed to aromatic amines ( rubber industry). It is suggested that as these carcinogens enter the body they can get filtered into the bladder, where they can then come into contact with the Urothelium. Men have an increased risk of these cancers probably because they are exposed to these risk factors more. Another risk factor is pelvic irradiation in which these can damage cels and therefore lead to mutations.
In other countries such as Egypt the major risk factor is a parasite called schistosomiasis, which lives in the water. It is capable of entering the body as the person goes into the water, and it will then penetrate through the patients skin. This can then travel in the body to various tissues including getting filtered at the kideny and into the urinary bladder, causing an infection and inflammation of the bladder wall. |
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What is the pathology of bladder cancer
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The main types of cancer which are involved with the bladder are transitional cell carcinomas. This is the cancer which occurs 95 percent of the time. The second type of cancer which can arise is a squamous cell carcinoma. This is often after schistosomiasis
Suggested that there is continuous inflammation and irritation which leads to metaplasia of the cells. |
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What are the patterns of the transitional cell carcinomas
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The transitional cell carcinomas can take three different types of pattern. There is firstly the ones which are superficial transitional cell tumours, which will extend into the lumen of the bladder. Then we hae transitional cell carcinomas that are invading into the muscle layers. Finally there is the carcinoma in situ. This is where there leison will be flat, and it has not extended into the basement membrane. Therefore if you imagine it, the tumour is not extending into the lumen like the superficial one.
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What are the clinical features of bladder cancers
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The most common clinical presentation is that the patient will complain of painless Haematuria, as the tumour erodes blood vessels and causing blood to weep out. Then there is urinary symptoms of frequency and urgency, as the tumour invades the wall and destruction and the contnets released can stimulate the nerves. Finally some patients can get recurrent urinary tract infections. This is because if the tumour grows and invades the wall and forms a fistulae between the colon and the bladder, allows organisms to travel down into the bladder. Obstructive symptoms can occur if the tumour is at the area that the urether enters the bladder.
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What investigations would you carry out for bladder cancers
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Urine investigations. The urine can be looked under a microscope and cytology can also occur to look for the blood and also if there is any cancer cells which may have been sloughed off.
To check the anatomy of the kidney an intravenous urogram can be used to check how the bladder is functioning and if it is filling. In addition to look at other parts of the tract and see if they are involved and have tumours. A cystoscopy can go into the bladder find the leison and then take a biopsy, and hence is the diagnostic tool. CT and MRI can tell you about the spread of the cancer |
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What is the epidemieology of BPH
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The Age group effected is often the elderly.
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WHat are the symptoms of BPH
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The symptoms can be divided into two.
There is symptoms which result from there being an obstruction. As the prostate squeezes on the urethra this can cause problems. First there is hesistency, simply because the obstruction means it takes longer for the flow of urine to get through. Then there is a “poorer stream” which results from the urethra getting squeezed and hence less is flowing through. Terminal dribbling, this is just from basically at the end of the force of urination, the last bits of urine passing through the prostate and hence dribbling out. The problems with the bladder. Due to residual urine remaining. During night time when we are lying flat, more blood is returned to the heart and hence the kidneys would hence be getting more supply. Therefore more urine is getting produced. In combination with this the bladder is not contracting as well, meaning more urine remains in the bladder and hence the bladder will fill more quickly giving the patient the necessity to urinate during the night. Along side this the frequency and urgency which are explained by the bladder wall being less good, and so more urine remains. |
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What are the complications of BPH
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Urinary tract infections are common, due to urine remaining in parts. From residual urine for example.
Hydronephrosis. As the kidney continuously produces urine, with an obstruction ahead, this means that the renal calycys can get distended. Again this is after chronic retention Renal failure can result after hydronephrosis. With enlarged tubes, this can cause damage to the tissue of the kidney, and hence with damage the kidney wont function. Therefore renal failure. Overflow incontinence. Acute urinary retention can also occur. This is where the patient suddenly can not pass urine and has pain which is down to the bladder wall stretching . To confirm it you need to do a cathether to measure the amount of urine in the bladder, and it has to be large. And the patient will have relief from the pain. |
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What are the examination findings in BPH
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A digital rectal examination must be carried out to find out the size of the prostate. Often the size of the bladder will be larger, also feel for any nodules which suggest cancer.
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What investigations are carried out for BPH
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The most basic investigation is giving a patient a questionnaire. The best example is the IPSS. IPSS is the international prostate scoring system. This is basically a questionaire and in the questionnaire there is the symptoms such as frequency, urgency, nocturia, hesitancy and they are told to score it. The last category is the quality of life score. The score can thus be used to tell you how bad the BPH is and can hence direct management options.
Urinalysis can tell you if an infection is present with the nitrites. U and Es can also check the kidney function. Flow tests. This is basically where the patient is asked to urinate into a device. This device has the ability to measure how fast the urine comes (flow velocity) and how much has been passed. The post void-residual volume can also be done which is where an ultrasound probe can measure the amount of urine left, non invasive. Cancer Investigations PSA. This can tell you about the patients risk of a cancer. In addition. Transrectal ultrasound can be followed by this. |
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What is the medical management of BPH
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There are two drug treatments available for patients. There is firstly drugs which block alpha receptors, ie the sympathetic nervous system. This is present on the smooth muscle of the prostate. By blocking here what we get is that the squeezing effect is reduced.
Then we have the 5alpha reductase inhbitors, which prevent the formation of testosterones active product inside the cell, called dihydrotesterone. Hence this cant go onto the dna and activate genes which tell the cell to divide and also cause the cell to grow. |
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What is the surgical management of BPH
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The surgical treatment is called Transurethral resection of the prostate. This is where a tube is inserted into the urethra, at the end of it there is a loop and this basically just shaves away parts of the prostate. Complications of this treatment include
TUIP. This is transurethral incision of the prostate. Here a cut is made into the wall, and hence by doing that the wall gets wider. Look at photo below. Prosectomy. Which is where prostate tissue is cut away. Laser treatment. This is basically inserting the instrument into the urethra, and then the laser will zap away parts of the prostate. Stent can be placed as well to widen. |
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What is prostatitis and the clinical features
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This is where you get an infection of the prostate. The typical organism which causes this is E.coli, and is often caused by a reflux of urine from the urethra into the prostate. This leads to an inflammation. The clinical features patients may have are systemic upset with fever, chills, rigors. The inflammation itself can lead to there being pain felt by the patient often at the perineum and the suprapubic area. They may get typically urinary tract infection features of increased frequency, urgency, and painful urination.
But also inflammation can squeeze the urethra and lead to decreased stream, terminal dribbling, hesistancy. The examination of the prostate will reveal a swollen and tender prostate. Managed by antibiotics |
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What is polycystic kidney disease and its pathology
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Polycystic kidney disease is where there is the formation of cysts in the kidneys. This tends to be caused from inheritence of mutated genes. The genes affected are called the PKD1 or PKD2 gene. Suggested that you need mutations in both of the genes, and hence the patient may get this mutation to this second allele due to a second hit in order to develop the cysts. The protein of the PKD genes is thought to be responsible for the cell interactions outside the cell and its ability to join to others. It is unknown how this then leads to cyst formation. However, it causes the tubular cells to divide more, and then at the centre will be fluid which is formed from the filterate and also the tubular cells ion movements and fluid movements they are carrying out.
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What are the clinical features of polycystic kidney disease
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The presence of the cysts can stretch the kidney and thus cause pain.
Hypertension is thought to be caused from the cysts which compress the blood vessels, meaning a lack of flow will occur and hence the RAAS system will get stimulated more often. The cysts tend to have a good blood supply surrounding them. This can rupture these blood vessels which bleed into the cyst and rupture it meanin blood gets into the urine and hence hameaturia. Acute pain can be caused if the rupture into the cyst causes it to enlarge. Patients are more vulnerable to infection as well, where infections can occur of the cysts. After the cysts form and destroy the renal tissue patients can develop renal failure. This disease can also effect other parts of the body as well. This includes the liver, with liver cysts forming here as well. The brain can get affected with berry anneurisms and subsequent SAH forming, which may be linked to the hypertension. Finally some patients have valve problems such as with the mitral and aortic which is probably linked to the hypertension |
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What investigations would you carry out for Polycystic kidney disease
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The main investigation to do is an ultrasound which can show the presence of cysts at the kidney. May consider doing genetic tests as well to find mutations in the gene. It can also be considered to screen for berry anneurisms using a Magentic resonance angiography.
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What is the management in polycystic kidney disease
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The treatment first involves targeting the hypertension which is caused from the kidney disease. This is because it can cause the patient to increase their risk for cardiovascular disease. As the disease progresses may need to consider dialysis and transplantation as ESRF occurs. The pain can also get targeted by removing the cysts laproscopically.
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What is the definition of acute kidney injury
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The definition of ARF is when the function of the kidney decreases. This can occur in a short time frame from hours to days.
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How can we divide the causes of acute kidney injury
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The causes are naturally divided into three main domains: pre-renal, intrinsic and post-renal.
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What are the pre-renal causes of AKI
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The pre-renal causes can be thought of as things which affect the blood supply to the kidney. So without the blood properly perfusing the kidney this means that you are holding onto the toxins and wastes. The causes of pre-renal include hypovaleoma and hypotension.
Then we have other ones which include sepsis as this has the ability to induce a vasodilation. Then there is drugs such as NSAIDs which block prostaglandin so the autoregulation at the kidneys is affected. Whilst ACE also has an effect because it will prevent angiotensin II from vasoconstricting the efferent ateriole. Renal artery stensosi as flow to the kidneys is reduced from the narrowing . Then medical conditions such as CCF as the cardiac output will be poor to the kidneys, and also hepatorenal syndrome from cirrhosis.. Due to liver failure the supply to the kidney is affected and perfusion. |
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What are the renal causes of AKI
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Renal/intrinsic causes are where we have problems will the kidneys themselves. When thinking about this it is especially down to the necrosis of the tubular epitheal cells. This necrosis can be caused from 2 pathologies. It could be from ischemia such as Acute tubular necrosis , which is where the pre-renal causes lead to a decreased supply to the kidneys leading to the ischemia and necrosis of the cell. Secondly there is toxins causing ATN, where toxins directly secreted into nephrons will have a direct effect on the tubular epithelial cells causing its necrosis. As the tubular epithelial cells are not present they can not carry out their function. The dying tubular cells can even get sloughed off and block the tubule. The toxins capable of causing toxins ATN include:
Antibiotics such as gentamycin, amphoterin Bb. Toxins made in body ie Hb and myoglobin. Myeloma as the light chains produced can directly damage the tubuler cells. radiological contrast: the agent used has ability to damage the cells. Now there are also a range of other causes which you need to consider. This includes interstitial nephritis which tends to be from drugs such as antibiotics and NSAIDS. Also glomeruonephritis. Finally you need to consider causes that are down to damage to the blood vesels. This is Haemolytic uraemic syndrome: This is because the toxin attacks the endothelial cells and clots will then form. TTP: This is a disorder in which patients form clots in the circulation a lot. Vasculitis |
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What are the post-renal causes of AKI
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Post-renal causes are just anything which causes an obstruction. So this includes renal calculi, tumours, prostate, catheters, sclerosis.
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What blood investigations are carried out in AKI
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Full blood count: This can be helpful in telling you if it is an acute or chronic problem.
Urea and electrolytes: Creatinine and urea are helpful as they may be raised, and its important to get the baseline as well. Pottasium is the ion you should be aware of as it can be raised. Liver function tests: This can check if there is any cirrhosis. Calcium and phosphate: Again help you work out if chronic or acute. CRP: This can tell you about any infection. Blood cultures: This can check for sepsis ABG: as ph can get affected and also in sepsis. Bence jones proteins: To see if there is myeloma CK: Check for rhabdomyelitis. |
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What additional tests are carried out in AKI
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Urine dipstick
This is good to check quickly for infections with the wcc and the nitrites. Also good to see if blood or protein suggestive of glomerular disease. Urine microscopy This can tell you a great number of things. The White cells may be raised due to an infection. There may be glomerulanephitis with the red blood cell casts. Crystals may be seen due to uric acid. ECG This is an important ivnestigation to ensure to monitor the potassium. Imaging. This is done with a renal ultrasound as it can tell you two things. First it can tell you if there is acute or chronic with the size of the kidney. Secondly it can show if there is an obstruction present. Finally a CXR is useful because patients may get fluid overload and hence pulmonary oedema is a wory. The reason patients get pulmonary oedema is because patients may accidently get fluid overloaded due to the incorrect matching of fluid outputs and inputs. |
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What is the management of pre renal AKI
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The causes again we can split into pre renal, renal and post renal causes.
Pre renal. Look for causes of hypovolaemia and also sepsis. This can be achieved by looking clinically for signs of these and if the volume is low. This includes seeing if the blood pressure is low, high hear rate, decreased JVP, the skin turgour would also be poor. Certain drugs such as the ACE and NSAIDS should be stopped straight away. This can then be managed by giving the patient appropriate fluids in order to ensure the kidney gets perfused. If the patient is septic manage the sepsis, such as blood cultures and antibiotics. |
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What is the management of intrinsic AKI
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Look for the clinical features of the intrinsic renal failure. If ATN is the cause, the treatment of this is just ensuring that the kidney gets blood and perfusion therefore. The conditions of GN can be treated with sterioids and immunosupressants for example
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What is the management of post renal AKI
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This is where an obstruction is considered. The obstruction in only some causes may lead to anuria, which is where no urine is produced at all by the patient. On examination you should aim to feel for a palpable bladder, the prostate, or any masses. An ultrasound scan is then required of the kidneys to check the anatomy to see if there is an obstruction as this will show dilation of the renal pelvis and calyces.
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What is the general management of AKI
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Fluid monitoring and management is required. The patients fluid status should be measured via heart rate, blood pressure, central venous pressure (needs cathehter), a urinary cathehter, taking the patients weight. You should note the loss of fluid via the urine, vomit, drains, dirrheoa and then match this with the appropriate fluids. This is vital because you need to ensure that because the kidney is not working as well, you do not end up putting too much fluid into the patient as they can thus get fluid overloaded. Patients are often given an extra 500 Ml so that
Nutrition is important. This is because urea the toxic compound is getting accumulated in these patients. So you want to restrict its formation. As protein is the main nutrition which when metabolised produces urea, we need to ensure that this is restricted. In addition giving calories with fats and carbohydrates is useful, because it will give the body the required energy source, rather than breaking proteins down for energy. This is a catabolic state, and often in sepsis and burn patients this is the problem. Choosing the required route also needs to be considered, as the oral may be affected, may need to give nasogastric tubes etc. Drugs which are prescribed for the patient need to be carefully prescribed. The patients medication should be reviewed so that any nephrotoxic drugs are not prescribed. Also a number of the drugs can get excreted by the kidneys, therefore you need to change their doses. |
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What are the complications of AKI
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One major electrolyte complication you should be worried about is hyperkalaemia. This should be monitored by getting the plasma levels and also the ECG. This should then be treated with the appropriate management such as calcium gluconate, insulin and glucose, beta 2 agonists, calcium resonium etc.
The second major complication is pulmonary oedema. This needs to be treated by sitting the patient up. They should be then given morphine as it can dilate the blood vessels. Then furosemide is required 120-150mg iv. Some patients may require ventillation support to help keep the alveoli open in the use example CPAP. More susceptible to infections because the various tubes and also obstructions. So ensuring you look of for clinical signs of infection with examination |
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When should dialysis be considered for AKI
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Some patients will require the assistance of dialysis to take over the kidney function. The criteria for this in acute renal failure is basically when the functions of the kidney are really bad. This includes Pulmonary oedema which continues coming back, acidosis which is severe less than 7.2, high pottasium count greater than 7mmol/L, uraemic encephalopathy and uraemic pericarditis( pericardial rub)
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What is acute urinary retention
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Acute urinary retention is defined as the inability of the patient to urinate, with abdominal pain. Once a cathether is placed into the area to drain the urine the patient then gets relief. The volume which is drained must also be a large volume.
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What are the causes of acute urinary retention
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The most common patients this occurs in is men. The reason it may occur is due to blockage of the urine flow which in men can be due to BPH or Prostatic cancers. In addition it could be due to a stricture which is present in the urethra. Acute urinary retention is also common after surgery particularly around the pelvis. The reason for this is thought to be due to pain around the area, and hence patient can not utilise the muscles properly to help push the urine out. Could be due to anaesthetic medication given to patients which could effect the autonomic neurons and their ability to cause the muscle to contract or the sensory neurons, which prevent the message that the bladder is full to the brain. Other medication which block acetylcholine can also be a cause. Other less common causes include neurological issues such as spinal cord compression (affects the nerves).
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What are the examination findings of acute urinary retention
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On examination of the abdomen you would be able to palpate the distended bladder. If it is really enlarged it may extend up to the umbilicus. On percussion you would hear a dull note.
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What is the management of acute urinary retention
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The management you need to do is to drain the urine, and this is achieved via a cathether. However if this fails there is the option to place the cathether into the area suprapubically so through the abdominal wall
The drained urine should be analysed particualry its volume as this can help confirm the diagnosis, because remember it has to be a large volume. The reason this is an emergency is because with the pressure build up in the bladder, it can effect things much higher up and lead to a post-renal problem causing renal failure. You should examine the prostate to see if its BPH or cancer. A treatment should be applied before the cathether is taken out. This includes giving patients TURP if its BPH. Those with post surgical retention you don’t really have to do anything apart from keep the cathether in place until a few days later when they have regained strength and less pain. |
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Is renal stones more common in men or women
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Men
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Why do renal stones form
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The reason that stones form is that there is an extremely high concentration of the ingridient in the kidney which then allows it to join together.
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What types of renal stones exist
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There are different costituents of the stone. The most common type of stone is from calcium oxalate which accounts for 75 percent of stones. Most of these patients don’t have Hypercalcaemia, however they instead have a condition in which the intestine absorbs large amounts of calcium which then get excreted into the kindey and this is called hypercalcuria. Then there are patients who have high amounts of oxalate, and this can be due to eating food like strawberies, and chocolate which contain high amounts of this.
The largest type of stone is a mixed stone which consists of magnesium, phosphate and aluminium. This is called a staghorn stone and it is called so because it looks like it has horns on examination. The reason it develops is often from a bacterial infection which will then release enzymes that chanes the PH and makes it better conditions for the stone to form. Urate stones can form and this may be due to patients producing large amounts from gout or they have a cancer. Cysteine stones are the rarest type and they form from inherited conditions in which there is problems with the nephron in absorbing amino acids and so they form a stone. |
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Where can the stones be located
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The location in which the stones can lodge themselves can differ. However there are three common areas it can occur. It may occur at the junction between the renal pelvis and the ureter. Then it may lodge in the ureter itself and this often occurs where it becomes slightly narrow as it passes over the pelvis bone’s rim. Then it can lodge itself at he point where the ureter enters into the bladder.
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What are the clinical features of renal calculi
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The clinical feautres of renal calculi is firstly that the patient will get pain. This pain is from the spasm of the kidney trying to push the stone along. This can be in waves and this is called uretric colic and is when the stone impacts the ureter. Then this stretching can cause nausea and vomiting. The stone rubbing against the tubes can lead to Haematuria. Depending on the location of the stone certain symptoms can occur including decreased urine output.
The patient with ureteric colic will characteristically been in so much discomfort that they can not remain still. The pain tends to be radiating down the loin towards the groin and testes. This is referred pain. If the stone is in the bladder and ureter junction may get pain whilst passing water. Due to the stasis of urine it can lead to an increased chance that the patient may develop a UTI. |
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What investigations are carried out in renal calculi
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A full blood count is carried out and this can tell you about any infections.
A Urianlayiss can see if there is any blood in the urine or a UTI, and also a MSU and culutre to check for infetion. The main investigations to carry out is to check the renal function to begin with. This is by doing Urea and Electroyltes. Also checking the levels of the certain stone ingridients. This includes checking the calcium, phosphate, uri acid. You can also check in patients with recurrent stones with a 24 hour urinary collection. This can check first the renal function with creatinine and urea levels. But also can check levels of certain stone ingridients. This includes calcium, phosphate, oxalate, uric acid. The imaging for stones is firstly by doing a Kidney, Ureter and bladder Xray. This can show 90 percent of stones. The Renal ultrasound can confirm the presence of the stone and also hydronephrosis due to obstruction. The best test however is a CT scan. Sometimes you cant do IVU. |
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What is the management of renal calculi
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The medical management is to give the patient fluids and this can help flush the stone out. Also analgesis for the pain. You may need to treat UTI if it is present as well.
The management after this will depend on the size of the stone. Those with a stone less than 5mm in size, 90 percent of cases it will flush out within 48 hours or 30 days. Also if there is obstruction is occurring you want to treat because of hydronephrosis and kidney damage likely to occur. If the size of the stone is less than 1cm then we can use ESWL, which will use ultrasound waves to destroy the stone intos mall framenets whih can then easily pass out of the body. PCNL is where from outside of the body you can place a tube whih enters into the kidney pelvis and then either damaes the stone or ollets it. This is done for large stones of greater than 1 cm. The final treatment can be with arthroscopy which is placin the scope up the trat and lasering it or collecting it. |
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How can you prevent renal calculi
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To prevent the stones forming you should tell patients to drink plenty of fluids. Now also you can do specific things for certain stones. If high calcium then can give thiazide diuertic because it can lead to increased absorption of calcium. Tripple stones of MG, phosp, aluminium you should treat the infection.
For high levels of urate can give patients Allopurinol. Cystine you should tell them to drink lots of fluids. |
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What is the pathology of testicular cancer
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Chromsome 12: found in tumours which suggests there is a gene on here that is being affected.
Undescended testes because high temperature of abdomen has an effect on their divisions allowing erors to occur |
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What is the epidemieology of testicular cancer
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It is more common in white people than Asians and blacks.
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Describe the pathology of testicular cancer
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The most common type of tumours evolve from your sex reproductive cells ie the germ cells. Broadly speaking there are two types which exist; Seminoma germ cell tumours and Non seminoma germ cell tumours. The seminoma germ cell tumours are those which occur in germ cells that resemble the sperm cells. However we can get Non seminoma germ cell tumours which will develop into different types of cells. This includes Teratomas(monster tumour) which contains a vast range of cells from embryology including ectoderms, mesoderms and endoderms meaning that the tumour can have different types of tissue inside it like hair and teeth. Secondly there is Yolk sac tumour which contains cells from the yolk sac. Thirdly there is Embryonal carcinoma which has cells similar to the inner mass of the blast cyst. Finall there is chriocarcinoma which has cells similar to the trophoblast. So remembering the embryology is useful here.
Now there are also tumours which develop from the other cell types in the testes , these are rarer. They include Leydig tumours and Sertoli cell tumours. Whilst others have lymphomas which have probably spread. |
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What are the clinical features of testicular cancer
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Is that patietns will notice a solid hard lump that is often painless. You ca palpate above the lump.
More rarer presentations are those associated with mets, with back ache due to spread the lymph nodes, or shortness of breath due to mets at the lungs. |
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What investigations are carried out for testicular cancer
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Ultrasound scan can help look at the lump and show if its solid.
Tumour markers are helpful in this cancer. There are three to be aware of. Alpha fetoprotein useful in patients with teratomas. Beta HCG useful in patients with non seminoma germ cell tumours, especially chorio as this contains trophoblast cells which secrete this hormone. LDH is a good indicator because it gives you a clue about the size of the tumour. Staging can be done with a CT scan. |
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What is the management of testicular cancer
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Before treatment patients can have their sperm stored called cryopresevation. This is because obviously removing the testes will affect fertility as well as the adjuvant therapy that is done as well.
The management is split depending on the type of tumour it is. Both will have a surgery to the testes which is where it is removed and the spermatic cord is removed. This is called radical orchidectomy. Now depending on the type of tumour and also the stage of the disease, the adjuvant therapy is dictated. Seminomas are treated with radiotherapy as they respond well to this after the surgery. Sometimes chemotherapy is added on for disease spread more. This is with BEP; bloodying, etoposide and cisplatin Non seminoma germ cell tumours such as teratomas are treated with chemotherapy. Further surgery may be required which is removal of the lymph nodes as well. |
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What is the basic processes involved with chronic kidney disease
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To understand chronic kidney disease, the kidney function is continuously detonation. Nephrons are bein lost and getting scared. The remaining nephrons will then take over the kidney function. However the load they are taking upon will be increased. Therefore they will eventually get damaged.
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What is the definition of CKD
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Patients wont begin to get symptoms until they have reached a certain stage of CKD, as the other capable nephrons are able to carry out the function. There are 5 different stages of CKD, which is based upon the GFR.
1 >90 Normal or ↑GFR with other evidence of renal damage* 2 60–89 Slight ↓GFR with other evidence of renal damage* 3 A 3 B 45–59 30–44 Moderate ↓GFR with or without evidence of other renal damage* 4 15–29 Severe ↓GFR with or without evidence of renal damage* 5 <15 Established renal failure |
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What are the major causes of CKD
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Diabetes mellitus can lead to a condition called diabetes nephropathy. It causes this by glycoproteins being formed more which then get deposited. The basmenet membranes infrastructure affected leading to loss of negative charge. Also in Mesangial cells causing prolferation and then it squeezing and compressing capillaries. The second main cause is hypertension and this is from the sheer force of the blood against the Glomerulus and the subsequent damage to it.
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What are the less common causes of CKD
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Other causes are the same as acute renal failure: Renal vesse disease, Glomeruluarnephritis, polycystic kidney disease, interstitial nephritis, analgesic nephropathy, renal stones. More rarer causes are vacuities, sle, Myeloma, Amyloidosis, renal tumours, Alports syndrome and Fabry‘s disease (missing an enzyme which causes accumulation of toxic products inside the cells).
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What is an early symptom of CKD
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An early symptom of chronic kidney disease is Nocturia. This reflects the poor functioning of the kidney and the loss of cells which can not longer absorb the fluid.
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What are the symptoms of CKD
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Problems with Toxin removal.
High levels of urea can accumulate in the body. This can lead to the CTZ getting stimulated from this toxin so patients can have nausea and vomting. The urea can reach the saliva and as a result the patient can get a metallic taste. Anorexia is also present probably down to the metallic taste and nausea feeling. Hiccups which is suggested to occur from the stimulation of the diaphraghm. Now the urea can also get deposited in other tissues. This can include the heart and damage the Myocytes and cause pericarditis and cardiomegaly. The toxins reach the brain and affect the neurons leading to encephalopathy. Hormonal problems. The kidneys are responsible for secreting EPO. As a result low EPO means less production of red blood cells and patients can get a normocytic Normochromic anaemia and have symptoms of this. Calcium. The renal system will contain enzymes that activate Vitamin D to its final form called 1,25-dih The function of this is to absorb the calcium from the intstine. So without it being produced as much this means there will be less calcium getting absorbed which then will lead to the activation of PTH. Osteoclasts will then churn at the bone to release calcium. So as a result patients can et bone pain, and also the increased amount of digging can cause osteoporosis. Also osteomalacia which is softening of the ones, as less calcium. The phosphate will decrease because the PTH would lead to an affect on the renal tubules trying to increase the amount of calcium reabsorption, but this also causes phosphate to get secreted as well. Blood vessels Hypertension because the patient may already have high blood pressure. Fluid overload can occur because the kdienys are not excreting the sodium. Neurological Restless Legs syndrome is considered to occur from the encephalitis which may lead to there being periphral neuropathy. Some patients may get Myopathy. This weakness is thought to be due to multifactor reasons for example it coud be just down to electrlyote disturbances which then affects the action potentials of the muscle cells. Skin Problems Dry skin can occur because the sweat glands can get affected by an unknown mechanism. Phopshate deposition itching calcium phosphate deposition at the skin. |
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What are the clinical signs of CKD
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Starting at th hands you may notice that the nails have a brown discolouration to them. This is due to the kidneys being unable to get rid of certain hormones such as beta MSH, which can then stimulate melanocytes present here. There may be dry skin and they would may also be itching, which can lead to excoriation marks. Now also can get purpura and bruisng which is thought to be due to high levels of urea which can affect the functioning of platelets.
Yellow colour to the skin may be seen du to products normally being excreted by the kidney such as carotenoid and getting deposited here. The skin may also be pale from the anaemia. Blood pressure can get raised which can be down to fluid overload, sodium absorption or RAAS. This can cause cardiomegaly. The fluid overload can cause pulmonary oedema. The uraemia can also affect the heart and so you may hear a pericardial rub or pleural effusion |
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What are the main investigations in CKD
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Bloods
FBC: Anaemia which is normocytic Normochromic anaemia. U&e: The creatine and urea are raised. So would the potassium ABG: Acidosis ESR: Vascular scren. Glucose: Diabetes mellitus Renal Osteodystrophy: Calcium low, phosphate high, pTH higgh, ALP high from increased bone reabsorption. Urine : Dipstick the urine and see if there is proteinuria, haematuria. MSU: Doing a culture of the urine to check for infections. 24 hour urine collection as well can help the diagnosis. Imaging. Ultrasound to check the size of the kidney and they may be small from the damage and scarring. CXR can look for pulmonary oedema, cardiomegaly, and pleural effusions. Bone xray: To look for signs of renal osteodystrophy. Biopsy may be required if you don’t really know what the cause is. |
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What is the management of CKD
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The management is based upon the different problems the renal failure causes and how to treat them.
Lifestyle and Diet. Lifestyle advice first involves just trying to get the patient to stop smoking, alcohol, excersise etc, in order to reduce their cardiovascular risk. The diet is important. The first thing is to try and reduce the amount of sodium as this will have an affect on the fluid overload and also blood pressure. Another nutrition which should be reduced is protein, as certain studies have found that if this is restricted it will slow the progression of the renal failure. If the patient has issues with their potassium then you should also restrict this as well. Acidosis. This can be giving the patient sodium bicarbonate supplements to mop up the acid. Anaemia. This can be treated by giving the patient EPO. Calcium and phosphate. The calcium and phosphate issues is that the calcium will be low and the phospohate is high. Now these patients tend to have due to this a raised PTH. Now a high phosphate will also lead to the secretion of more PTH. Therefore you should try and reduce this. This can be done by preventing the diet intake of phosphate. In addition we can give calcichew which will bind onto phosphate in the GI tract and thus prevent the absorption of this ion. Another problem is that because the kideny is not functioning we will get vitamin D not being converted into its final form of calcitrol. Therefore we can give the patient Vitamin D analgoues example is Alfacalcidol, and also we can just give the patient calcium supplements as this is low. Cardivascular Disease, Blood pressure and Oedema As patients are at an increased risk of developing atheroscelerosis due to the increased blood pressure, they should be covered. Therefore first of all treating the blood pressure is important. This not only helps reduce the formation of atherosclerosis but also will help reduce the damage to the kidneys. So you should aim for a bp less than 140/85, and even less for diabetics 130/80. So may require to use ACE inhibitors. Then the oedema can be targeted by getting rid of the excess fluid with loop diuretics such as furosemide 250mg and Mettlesome (also the sodium and fluid restirctions can help). The atherosclerosis can be targeted by giving the patients statins and also aspirin to reduce the formation of clots. Restless Legs Syndrome. This is just targeting the neurons and settling them down and this is with gabapentin and Clonazepam (benzodiazpine). |
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What is dialysis
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Dialysis is a treatment that will do the work of the kidneys artificially. The aim is to remove the toxins that are built up in the body, and sort out the electroylte and acidotic issues the patient may have
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What are the two main types of dialysis
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There are two types of dialysis. Haemodialysis and Peritoneal Dialysis. The choice of which dialysis is based upon patient preference.
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Describe haemodialysis
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Haemodialysis is the techinque where blood from the patient is removed, taken into a machine, which has a semi permeable membrane and the toxins move out through the membrane. What happens is that this fluid is called a dials late and has special chemical compontents which allow substances to move into it, but also substances can move out of this fluid and into the blood.
Patients tend to require an operation before they are suitable for haemodilayiss. There is two options. The first is creating an aterio-venous fistulae at the forearm using the radial artery. What happens is that the artery and the vein are joined together, the increased blood and pressure in the vein will create changes in that vessel. This is mainly making it more thicker. The reason for doing this is that when blood returns to the body from the dialysis machine, it is strong enough to withstand this blood. Some patients may have poor blood vessels, and therefore a fistula is not created. Instead some patients may get a graft instead, which connects the artery to vein. Again this is done at the forearm. Now what happens is that after some weeks or months, the patient will then be ready for haemodialysis. They will then get once needle and tube into the artery, this takes blood away, and another needle into the vein and thus takes blood into the body. The blood is taken into the machine to the semi permeable membrane and exchages which occur on the principle of osmosis and also high concentration to low concentration will occur between the blood and the Dialyslate fluid. |
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What are the disadvantages of haemodialysis
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The issues with Haemodilayis is that patients will require to come into hospital for the treatment. Stay in hospital for around 3-5 hours, and come in around 3 times a week. Due to this the patients diet needs to be more carefully managed than Peritoneal Dialyiss.
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What is peritoneal dialysis
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Peritoneal Dialysis is the second type of Dialysis and it involves a surgical treatment where by a cathether into the abdomen. It works on the principle that dialcylte fluid is entered into the abdomen, and fills it up. The peritoneum has a semi permeable membrane as well as blood vessels. This means that we can use the semi permeable membrane in the peritoneum. The dialyslte will get pumped into the abdomen through the cathether, and then allowed to sit in the abdomen and exchange will then occur. The fluid will then get removed from the patient.
There are two types of peritoneal dialysis which are available. The first is called Continous Ambulatory Peritoneal Dialysis. This is where the patient throughout the day will themselves insert the fluid and remove it. This is done about 4 times a day. The second option is called Automated Peritoneal Dialysis which is where a machine at night will pump the fluid into the abdomen and remove it. |
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What is the benefits and disadvantages of peritoneal dialysis
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The benefits are simply that a less intensive surgery is required, don’t have to go to hospital, can get on with their life and work as the fluid just sits in them. A less diet restriction is needed because they will continually have the fluid inside them. The treatment will require more indpendence from the patient to do the treatment.
The main complication of P.D. is that bacteria can enter into the bowel and cause peritonitis. |
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Describe the pathology of glomerularnephritis
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When thinking about this you should remember the simple anatomy of the glomerularus. There we have the capillaries, the basement membrane and the podocytes which is inside the bowman’s capsule.
To understand this disease you should aim to simplify the pathology. So beginning with there is an immunologically determined with immune complexes or material deposited here leading to an inflammation. Secondly it can be from a direct attack by the immune cells to the tissue. The glomerulus will respond in a certain way to lead to structural changes. Now, you should understand that the resultant problems of haematuira or proteinuria can occur, but sometimes one dominantes more than the other. If proteinuria dominates this is called Nephrotic syndrome. If haematuira dominates this is called Nephritic syndrome |
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What are the three features of nephrotic syndrome
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The Nephrotic Syndrome is diagnosed as a triad of three features. There is proteinuria, hypoalbuminae, and finally oedema.
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What is the pathology behind the nephrotic syndrome
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The pathology of this condition is that the changes which are occurring in the glomerulus will lead to there being a leakage of the protein , and this will therefore lead to less albumin being present. The oedema is thought to not occur due to the low oncotic pressure. However it is believed to result from sodium reabsorption from the activation of the RAAS, and aldosterone having its effect. The increase in the amount of sodium in the extra cellular space will lead to oedema, ie it going into the interstitial space and drawing fluid into here.
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What are the causes of the nephrotic syndrome
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The causes of Nephrotic syndrome are down to glomerularnephritis. There are a range of different subtypes of this which can lead to it. The second important cause to remember is in Diabetes where there is thicking of the basement membrane and the loss of the negative charge. Then there are more rarer causes including SLE where immune complexes are deposited in the structure
Amyloidosis from deposition of amyloid proteins which then damage the structure Medication such as rheumatoid drugs probably from the deposition of immune complexes. |
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What are the clinical features and complications of the nephrotic syndrome
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The oedema patients have is described as being gravity depenent. Which means it tends to occur in areas where gravity helps the formation such as the ankles. The oedema also forms in areas which have low tissue resistance, so can easily puff. This tends to be on the face at the periorbital areas. The patient or on examination of the urine may appear frothy. The reason it is frothy is because of the high protein content in the urine reacting with the contents of the air to form bubbles.
As patients are passing more proteins out of the body they become prone to infections. This results from them urinating out antibodies. There is an increased tendency of patients to develop Venous thromboembolisms as well. This is because of a loss of antithrombin III. With a loss of proteins the hepatocytes in the liver will produce more protein, but this also leads to the increased production of lipids and this causes hyperlipademia. |
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What investigations would you carry out for a patient with the nephrotic syndrome
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The investigations that are carried out are based upon two reasonings. The first is to confirm that there is Nephrotic syndrome. The second is to find the cause .
To confirm the Nephrotic syndrome a urinalysis would have confirmed originally that there is protein in the urine. However you must quantify the amount of urine. This can be done with a 24 hour urine collection, and often you find that the protein levels are above 3.5g/24 hours. Measuring the levels of albumin in the blood is also helpful with this also being reduced, less than 30g/l. The investigations you should carry out are those that are carried out in glomerularnephritis. however in addition to this you should try and quantify the amount of protein that is in the urine, and also the amount of albumin that has been lost. A renal biopsy is also necessary, as this can help diagnose the strange types of glomerulus change you get. As the patients lipid and cholesterol levels can get raised it is important to also check these values as well. |
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What are the different glomerularnephritis's identified from a renal biopsy
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1. Minimal Change Glomerularnephropathy. This is so called because when the biopsy is observed underneath a microscope the glomerulus appears normal. However when observed underneath an electron microscope changes are apparent. This includes the podocytes becoming infused together. Also there is an infiltration from white blood cells mainly T cells and there cytokines may affect the ionic charges present on the basement membrane. This type is often seen in children. It responds to sterioids to reduce the T cell function or immunsupresant medication.
2. Membranous Glomerulapthy. This is where there is immune complex deposition into the basement membrane. Often we can not find the cause of this however in some cases it can be down to drugs or infection, auotimune and malignancy (against the tumour antigens). When they get deposited into the basement membrane it will cause thickening and also scarring of the membrane. This is from the inflammation it causes here, and the subsequent loss of the negative charge. The biopsy would show the basement membrane being thickened and also the IgG and C3 being seen, as complement is activated. Treated with steroids. 3. Focal Segemental Glomerularnephropathy. As the name suggests there is focal, which means not all the nephrons are involved, it is segemental which means that only parts of the nephron are activated. The cause of this often is not found, yet HIV may be the reason. On the biopsy there is scarring of the capillaries and also the glomeurlus as well. 4. Mesangiocapillary GN. Where immune complexes are deposited, and the subsequent inflammation causes proliferation of the mesangial and capillaries. Two types exist. Type 1 mainly deposited in the subendothelail layer of the blood vessel. The susbquent damage also leads to the basemenet membrane getting damage. Type 2 is in the mesangial cells or basement membrane. |
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What is the management of nephrotic syndrome
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The management of this condition first involves treating the patients oedema. This can be achieved by giving diuretics or reducing the amount of salt they are consuming.
Patients infections should be treated with antibiotics and also you should give patients pneumococcal vaccinations. As patients are more likely to clot, you should give them anticoagulation therapy. Now as there is an increased risk of hyperlipidaemia you should offer patients statins to reduce this. Ace inhibitors are used because having proteinuria can increase your CVS risk. This will reduce the amount of proteinuria probably because it can reduce the blood pressure meaning there is not as much force which pushes the protein through the glomeurlus. |
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What three causes are capable of causing nephritic syndrome
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Post-streptococal glomerularnephritis. This is a condition which follows a streptococcus infection such as the throat. It is believed that immune complexes would have formed and got deposted at the capillaries (glomerurlus). This then triggers an inflammation. The neutrophils that arrive to the area will release cytokines and then its contents will damage the blood vessel, leading to blood in the urine. Pathologically you also get a proliferation which can therefore lead to reduction in the blood flow and the GFR leading to oliguria. Investigated with a biopsy which would show igG and C£. Then bloods to look for the antibodies against the streptococcal infection.
SLE is a condition which can lead to the formation of immune complexes and this can then lead to deposition in the glomerlus and this leads to inflammation. igA nephropathy is where we have the being a deposition of igA into the mesangium. This leads to activation of the complement system and damage to the flomerulus and hameturia will be caused. On investigation you would do a biopsy and this would reveal the mesanglial cells proliferating and deposition of igA and c3. Treatment is with immunosupressants so steroids and cyclophosmaide. Important to remember that a systemic form of this is called Henonch-Shonlein purpura in which patients will get a petechial rash, abdominal pain and also this glomerular nephritis. |
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What is the third pathological change leading to nephritic syndrome
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The third pathological issue is that there will be severe damage to the glomerulus. This allows the contents of the blood into the bowman’s capsule. The epithleila cells which are lining the bowman’s capsule will then react. A structure known as a crescent will form.
Goodpastures syndrome. This disease is where there are antibodies which will attach to a collagen that is located in the basmement membrane of the kidney. However there is also basmement membranes present in the alveoli within the lungs. So once the antibodies attach onto the membrane they will cause the recruitment of white blood cells into the area. As a result you get enzymes released by these white blood cells causing there to be damage to the blood vessel walls, leaking its contents and a response is initiated. Symptoms patients get are haemature and also due to the basmenet membrane in the lungs, hameoptysis. The formation of the cresent can lead to renal failure as it compresses the capillaries and hence oliguria. The treatment for this is suppressing the immune system. Therefore we use steroids. |
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Define Bacteruria
UTI recurrent infection relapsing infection UTI complicated and uncomplicated |
Bacteruria is when bacteria are present in the urine.
A urinary tract infection is defined when you grow greater than ten to the power of 5 organsims in a ml of urine from a MSU. A recurrent infection is when the patient gets a new infection from a new bacteria. A relapsing infection is when a patient gets another infection with the same bacteria. Urinary tract infections can be complicated or uncomplicated. Uncomplicated UTIs are those without any uinary renal problems. Complicated UTIs have problems affecting urinary renal. |
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What are the Upper UTIs and Lower UTI
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Depending on the location of an infection, there are different medical names. We can divide this into upper tract infections and lower tract infections. An upper tract infections is those affecting the kidney are called Pyelonephritis.
Whilst lower tract infections are: infections of the bladder are called Cystitis. Infections of the urethra are called Urethritis Infections of the prostate are called prostaitits. |
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What are the main risk factors for UTIs
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Women
Women are more affected than more for urinary tract infections. The reason for this is because of the position of the urethra to the anus and hence more easier for bugs to reach the area. Women who have sexual intercourse are at risk because the end of the penis which may have bugs on it can rub against this and hence allow bugs to enter into the urethra. Then we have contraception which utilised spermatic ides. These chemcials can kill the lactobacillus in the vagina, which then allows other bacteria to proliferate, and hence they can then travel to the urethra out of the vagina. Patients who are pregnant, because they will have changes to their renal system which promotes infection, for example they will have progesterone which relaxes smooth muscle and hence effects the flow of urine. Menopause is a risk factor because less oestrogen has a number of effects on the renal system, and also the vagina, which can change the PH and allow proliferation of bugs. Conditions Patients who are immunosupressed and diabetic are at an increased risk of developing infections. Urinary tract This can be from from any obstruction such as stones. Then we have cathethers which will basically just introduce the bugs into the urethra. |
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What are the common organsims associated with UTIs
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The most common organism is from the bowel and is E.coli. This bacteria is really good at infecting the urinary tract because first of all on its surface it contains receptors capable of binding onto the receptors that are present on the epithelial cells of the urinary tract. Other common organisms include Staphylococcus Saprophyticus, Proteus mirabilis, enterococcus Faecalis.
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What are the clinical features of upper UTIs
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This is an infection of the kidney which is called Pyelonephritis. It tends to occur due to an ascending infection from a lower tract infection. The clinical features of pyelonephritis is that the patient due to the cytokines released will get a fever, but what is also unique is that rigors can develop. Rigors is where the body shakes due to it wanting to raise the body temperature to the temp set in the hypothalamus, and hence the muscles contract in order to produce heat. Patients due to the inflammation and stretching of the kidney can get abdominal tenderness which is typically referred so can get pain down the loins. Now as the tissues gets necrosed acute renal failure can develp and block the tubules. As the kidney is not functioning the best build up of urea can thus lead to vomiting.
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What are the clinical features of lower UTIs
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Cystitis: The toxins from the bacteria, the contents of Neutrophils alive or dead can stimulate the epithelium and nerves. This causes frequency and urgency. The inflammation will lead to suprapubic pain. There can also be pain on urination called dysuria as the urine passes over inflamed tissue and mecahoreceptors giving a typically a burning and stining pain. Haematuira can occur due to the damage of the tissue.
Prostatitis:. This is where we get an infection and inflammation of the prostate. Again the most common organism involved is E.coli and also streptococcus Faecalis. This is often from bugs travelling up the urethra and then to the prostate. The clinical features patients get are firstly systemic features due to cytokines such as fever. Also can get a painful back due to the inflammation and the location of the prostate. As the vas deferns will travel into the prostate with sperm, the damaged prostate may leak blood into the sperm, and hence you can get haemospermia. The inflamed tissue can squeeze on the urethra and hence urinary retention can occur. Dysuria can occur when the urine passes through and presses on the inflamed tissue. On examination with a PR, you may find a swollen and tender prostate. The urethral syndrome is where patients will have symptoms of a urinary tract infection, however no organism can be found |
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What are the main investigations for UTIs
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General Investigations.
The first general investigations which can be carried out are FBC to check if the white cells are raised. An ESR/CRP can be used to see if there is inflammation. Then we can do a urea and electrolytes to see the geneal function of the kidney. A blood culture can also be done to check for sepsis. This is called urosepsis. Urine investigations. The investigations which can be carried in the urinary system is firstly a urine dipstick. This can just confirm if there is nitrities and also if there is a raised leukocyte count. The main test however is to ask the patient to do a midstream urine (MSU). This is where they will basically be asked to collect a urine sample more mid stream rather than at the start, as this will be contaminated. This sample is then sent to the lab. They will then culture it and try and grow organisms. This is then diagnosed if there is 10 to the power of 5 of growth of the organisms. The organisms are also tested to see which antibiotic they are sensitive to. Special Investigations. In some patients it may be necessary to do futher investigations. This is an ultrasound or IVU. |
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What is the management of UTIs
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The first management is conservative management. This is basically by ensuring the patient is hydrated as this can help flush bad material out the body.
The medical treatment for these patients is giving antibiotics. This will depend on some demograhpics of the patient. In adult women who are not pregnant, with a lower UTI are treated with trimethoprim or the alternative is nitrofurantoin. In these women with an UTI the are often treated with cefuroxime/ciprofloxacin. Pregnant women are requiring expert advice. Male patients will require a more cautious approach because it is more rare in these patients. Thus you may need to get a urologist involved especially if pyelonepritis or a recurrent UTI or antibiotics are not working. Typically you often give them a quinolone example is levofloxacin. |
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What prevention strategies for UTIs
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The basic advice is that patients should keep hydrated and also drinking cranberry juice or lingo berry juice can prevent the E.coli from attaching with its receptors to the cells of the tract. Some women can have prophlaytic antibiotics.
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What is an epididymal cyst and spermatocele
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These lumps are from enlargement of one of the tubules of the epipdymis. It thus contains more clear fluid which is an Epididymal cyst, however if the fluid contains sperm then it is called a spermatocele.
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What are the clinical features of epididymal cysts
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The characteristics of this lump is that due to the position of the epididymis which is posterior to testes, you tend to feel the lump behind the testes. They do not cause pain.
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What are the examination findings of a epididymal cyst
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On examination you will find four features. The first is that it is behind the testes often. Secondly as this structure is separate from the testes, it will feel like a separate lump. Thirdly there may be more than one lump. Finally if you should shine a light behind the lump. This is to test for Tran illumination, which is a test to see if the light passes through. If the light passes through the lump then it is a cyst
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What is the management of epididymal cysts
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Treatment is doing nothing, unless patient gets an discomfort can get removed. Often don’t want to do surgery incase you damage the structures leading to infertility.
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What is a varicocele
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A Varicocele is where we have varicose veins of the veins that are draining the testes called the pampiform plexus.
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Describe the anatomy of a varicocele and its clinical features
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The main teste which is affected is the left teste. This is because of the anatomy. The left vein will drain into the left renal vein. This occurs at right angles, where as the right vein will drain directly into the inferior vena cava, and this occurs at an oblique angle. As the left vein drains at a right angle, it means the flow will be less efficient and slow. The main reason this occurs is thought to be due to the insufficiency of the valves. As the veins hold onto more blood there can be two main problems occurring. The patient may complain of a dull ache and heaviness, simply as there is more pressure in the veins. The blood around the testes, can cause a higher temperature around the testes leading to fertility problems. On examination you will find that th veins feel like a bag of worms. If the patient lies down the veins will dpssapear because of flow back to the heart
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What is the management of a varcicoele
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The management of patients tends to be for those who have symptoms such as aching testes or fertility problems. They will undergo surgery in which embolisation can be used which blocks off the affected veins, allowing blood to travel in the good veins instead
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What is a hydrocele
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A hydrocele is where excess fluid accumulates in the tunica vaginalis. The tunica vaginalis is a bit of peritoneum which remains around the testes, due to the descent of the testes from the abdomen during development. It will surround the testes u to the epidiymits structure.
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Why do hydroceles occur
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The main reason hydroceles develop in children is that they have a patent process vaginalis, which is the peritoneum rope structure which lowers the testes down into the scrotum. Usually this would then join together and close up. However if it remains open it allows fluid from the abdomen to travel downwards into the vagianlis. Other reasons include there being a tumour or infection, as this just like the pleura will lead to inflammation and leaking of fluid.
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What are the different types of hydroceles that exist
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There are four types of hydrocele that exist. There is a patent vagianls process/congenital, meaning the hydrocele will most likely extend from the entire spermatic cord to the testes. Then we have vaginal where the hydrocele is just around the testes and hence the tunica vaginalis. Then you can have infantile where the hydrocele is around the testes but also extends a small bit up the processes vaginalis, however it will not have contact with the abdomen. Finally there is a hydrocele of the cord just occurs in the processes vaginalis anywhere above the testes in the spermatic cord.
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What are the clinical findings for hydroceles
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Patients will complain of a swelling. On examination you would see a swelling. Sometimes find it hard to even feel the testes. So this “lump” will be hard to differentiate between two objects of a testes and this lump. The lump would be Tran illuminating as it is clear fluid.
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What is the invx for a hydrocele
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Investigations that can be carried out include an ultrasound to ensure that the testes is still there and any other hard lumps. Then just doing tumour markers if you think its cancer, or also tests with urine for infection.
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What is the management of a hydrocele
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Management for some patients is just to do aspiration of the fluid, especially if they are not fit for surgery. Others can undergo a surgical procedure. What this involves is that the tunica vaginalis is cut, allowing the excess fluid to drain
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What is epididymitis
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Epididymitis is an inflammation of the epididymis
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What are the causes of epididymitis
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This is caused by an infection from a bug. It tends to occur due to a sexually transmitted infection; Gonorrhoea or Chlaymdia. Alternatively from a urinary tract infection that has travelled to the area, so E.coli for example
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What is the clinical features of epididymitis
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The clinical features is that the patient gets symptoms of inflammation so a swelling, pain due to the inflammation which has a sudden onset. The patient can also get cytokines released causing fevers and night sweats
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What are the invx for epididymitis
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Investigated simply by seeing if discharge and taking a swab, also taking a urine sample and checking for infections.
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What is the medical management of epididymitis
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The management is based upon the likely bugs which may be affecting the patient. Therefore in those patients who are under 35 years it is likely an STD, so treated with Doxycycline 100mg/12hrs for 10 days. In those above 35 it is more common for a UTI and thus they are treated with ciprofloxacin 300mg/12h for 10 days. Some patients may need analgesic to help the pain as well.
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What is orchitis
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Orchitis is where there is inflammation of the main testes itself. The most common cause for this is Mumps. Sometimes epididymitis can spread to invovle the testes. This is called Epididymo-orchitis.
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Define polyuria
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Polyuria is defined as producing large volumes of urine per day (above 3 Litres a day)
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What are the main causes of polyuria
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Diabetes mellitus as there will be glucose entering into the nephron and producing a osmotic diuerisis.
Increased fluid intake. Hypercalcaemia as this will have a osmotic diuresis effect in the kidney. Diabetes insipidus because this can lead to the dysfunction of ADH functioning and reabsorbing water. Addison’s disease as it will lead to decrease in the amount of aldosterone, and so less sodium and fluid reabsorption at the DCT. Drugs such as Lithium (nephrogenic DI) and diuretics |
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What is nocturia
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Nocturia is where a patient is wakening up during the night to go and urinate.
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What are the causes of nocturia
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The causes of this may just been from having polyuria or taking increased fluids or diuretics during the evening. The main causes you must consider are prostate problems and chronic kidney disease. In prostate problems it occurs because they will lie flat during the night, allowing better cardiac output and more perfusion to the kidney. And because they have prostate problems there would be already issues with the completely emptying their bladder, and so urine will be added to an already fullish bladder.
In chronic kidney disease you get |
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What is oliguria and anuria
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These terms are used to describe decreased volumes of urine produced. Oliguria is defined as volume below 400 ml per day. Where as Anuria is defined as the (almost) complete absence of urine (less than 50 ml).
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What causes should you consider with oliguria and anuria
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When thinking about the causes with oliguria you should think if there is Shock or if there is acute renal failure. In those with Anuria it suggests there may be a urinary tract obstruction.
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What is pneumaturia and its causes
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Pneumaturia is where you get gas bubbles seen in the urine. It is suggestive of two causes. The first is from a urinary tract infection with bugs that may be producing gas. Secondly there may be a fistulae that has formed between the bladder and the colon, which therefore allows air from the colon to enter the bladder. Conditions like diverticulitis, crohns disease and malignancy may be responsible for the formation of the fistulae.
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What does cloudy urine suggest
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Cloudy colour of urine suggests that there is an infection.
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Describe haematuria
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This is the presence of red blood cells in the urine. This can either been found microscopically during urinalaysis or can be seen visible and is called macroscopic/frank haematuria.
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What are casts
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Casts are the name given to the observation of cylindrical shapes. The reason they form is because they are moulded into the shape of the tubule which is the DCT and collecting ducts. The tubular cells here will secrete a protein which will cause the cells to join together. Now remembering the normal physiology the blood cells will not get filerted at the glomerulus. When we find red cell casts there is a suggestion there is glomerular disease. White cell casts can also occur. Also coarse granule casts which are proteins.
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