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Phase 2 Kate McDonald and Rebecca Marlor The Peer Teaching Society is not liable for false or misleading information Aims To understand the diagnosis, investigation and management of some common urological conditions The Peer Teaching Society is not liable for false or misleading information Introduction:

Benign prostatic obstruction Prostate Cancer Urinary tract infections (UTIs) Acute kidney injury (AKI) Chronic kidney disease (CKD) The Peer Teaching Society is not liable for false or misleading information Benign Prostatic Hyperplasia Definitions: BPH: Benign prostatic hyperplasia (histological) BPE: Benign prostatic enlargement (DRE)

BPO: Benign prostatic obstruction The Peer Teaching Society is not liable for false or misleading information Benign Prostatic Hyperplasia Common in elderly men (60-70 years old) Usually asymptomatic until late on Mechanism poorly understood Expansion of the central zone, effects both the glandular and connective tissue The Peer Teaching Society is not liable for false or misleading information Benign Prostatic Obstruction Storage symptoms

Symptoms Signs Frequency Smooth enlarged prostate on DRE, Palpable median sulcus Urgency Nocturia Overflow incontinence

Voiding Terminal dribbling Difficult initiation Poor flow/straining Hesitancy Overflow incontinence Inadequate emptying of bladder The Peer Teaching Society is not liable for false or misleading information Benign Prostatic Obstruction Differential Diagnosis: -Prostate Cancer -Urinary bladder Cancer -Bladder stone

-Urethral stricture -Prostatitis -Detrusor overactivity The Peer Teaching Society is not liable for false or misleading information Benign Prostatic Obstruction Investigations: -? PSA -Symptom questionnaire (IPSS) A man presents with LUTS and you think it is -Urinalysis probable he has BPH, what investigations would -U&Es (Creatinine), FBCs, you want

toLFTs arrange? The Peer Teaching Society is not liable for false or misleading information Benign Prostatic Obstruction Management: Conservative Watchful waiting Medical Alpha adrenergic antagonists (Doxazosin/Tamsulosin) 5-alpha reductase inhibitors (Finasteride) Surgical

TURP/prostatectomy The Peer Teaching Society is not liable for false or misleading information Acute Urinary Retention!! Causes: Benign Prostatic Hyperplasia 67 yearcancer old gentleman presents with 24/24 Prostate to pass urine (anuria) and 12/24

suprainability Prostatitis pubic abdominal pain? You suspect he has acute Neurological (disc rupture/metastasis) urinary retention? Urethral pathology Pelvic mass lesions/constipation What are the different causes? Anticholinergic drugs The Peer Teaching Society is not liable for false or misleading information Acute Urinary Retention!! Symptoms

Signs SUDDEN Inability to pass urine Bladder palpable and distended Supra-pubic pain Tender supra-pubicly Enlarged prostate Agitation

Anal tone Saddle anesthesia Upper and lower limb Power/reflexes/ EMERGENCY! Check for neurological deficits!! Dont measure PSA Catheterization Urine output ? Surgery The Peer Teaching Society is not liable for false or misleading information

Chronic Urinary Retention!! Incomplete bladder emptying Often asymptomatic, but can get LUTS + overflow incontinence, NOT painful! Acute on chronic retention Hydronephrosis + bladder hypertrophy -> chronic renal failure What serious complications do we worry about? The Peer Teaching Society is not liable for false or misleading information Chronic Urinary Retention!! Investigations: Monitor U&Es and urinary proteins Upper UT imaging

Management: Intermittent catheterisation ? Surgery The Peer Teaching Society is not liable for false or misleading information Prostate Cancer: Most common male cancer Hormonally driven - dihydrogentestosterone Adenocarcinoma, peripheral, ?multi-focal Localized Locally advanced Metastatic The Peer Teaching Society is not liable for false or misleading information

Prostate Cancer Symptoms ? LUTS Acute urinary retention Back/perineal or testicular pain Haematuria Stress incontinence ? Constipation, leg swelling Weight loss DRE: Asymmetrical nodular enlargement of the prostate What would you

expect to find on Hard and Craggy DRE? Loss of median sulcus Anorexia Fatigue ?Bone pain + pathological fractures The Peer Teaching Society is not liable for false or misleading information Prostate Cancer: Investigations: PSA TRUS +/- biopsy

?MRI/CT scan ? Isototope bone scan Gleason Grading and Clinical Staging The Peer Teaching Society is not liable for false or misleading information Prostate Cancer The Peer Teaching Society is not liable for false or misleading information Prostate Cancer Management: Localised Prostate Cancer Watch and wait Active follow up Radical prostatectomy

Radiotherapy (brachytherapy/external beam) Focal therapy The Peer Teaching Society is not liable for false or misleading information Prostate Cancer Management: Locally advanced Prostate Cancer Neoadjuvent hormonal therapy LHRH Agonists (Goserelin injections): hot flushes, lethargy, loss of sexual function Anti-Androgens: gynaecomastia, nipple tenderness, sometimes retain sexual function Radiotherapy The Peer Teaching Society is not liable for false or misleading information

Prostate Cancer Management: Metastatic Prostate Cancer: Hormonal therapies Chemotherapy/radiotherapy to improve symptoms and disease control Bisphosphonates The Peer Teaching Society is not liable for false or misleading information AKI Acute Renal Failure Abrupt onset (<48 hours) kidney impairment Sustained (>24 hours) reduction in GFR, UO or

both The Peer Teaching Society is not liable for false or misleading information eGFR Estimated Glomerular Filtration Rate Based on serum creatinine, age, sex and race Calculated using complicated mathematical equationModification of Diet in Renal Disease (MDRD) Normal < 100 ml/min/1.73m2 Independent risk factor for CVS disease The Peer Teaching Society is not liable for false or misleading information

AKI Classification NICE: Kidney Disease: Improving Global Outcome score (KDIGO) Officially (any of) : Rise in serum creatinine > 26mol/L in 48 hours >50% rise in serum creatinine within 7 days Fall in UO (<0.5ml/kg/hr) for >6 hours (adults) or >8 hours (paeds) >25% fall in eGFR in children and young people within 7 days The Peer Teaching Society is not liable for false or misleading information AKIN Classification Stage

Serum Creatinine UO criteria 1 Increase > 26mol/L within 48 hours or increase > 1.5-1.9X reference creatinine <0.5mL/kg/hr for >6 hours 2 Increase > 2 -2.9 X reference creatinine

<0.5mL/kg/hr for >12 hrs 3 Increase > 3X reference creatinine, increase >4mg/dl or started renal replacement therapy <0.3mL/kg/hr >24 hrs or anuria for 12hrs The Peer Teaching Society is not liable for false or misleading information AKI Aetiology RENAL

PRE RENAL POST RENAL The Peer Teaching Society is not liable for false or misleading information Classify the following causes.. A: Catheter blocked B: Congestive Heart Failure C: Haemorrhage D: Goodpastures E: Renal calculi F: ACE inhibitor G: Acute Tubular Necrosis H: NSAIDs I: Renal Artery Stenosis

J :BPH PRE RENAL, RENAL or POST RENAL??? The Peer Teaching Society is not liable for false or misleading information Answers Pre Renal Renal Post Renal B

D A C G E F H

H I The Peer Teaching Society is not liable for false or misleading information Pre renal COMMONEST CAUSE OF AKI Decreased intravascular volume Haemorrhage, shock, burns, D+V Decreased effective circ volume CCF, cirrhosis Drugs ACE, ARB, NSAIDs

Renal artery stenosis The Peer Teaching Society is not liable for false or misleading information Renal Acute Tubular necrosis (ATN) Secondary to hypoperfusion/toxin Red cells/granular casts Tubular interstitial nephritis (antibiotics, NSAIDS) Acute and chronic pyelonephritis Glomerulonephritis * Hepatorenal syndrome

The Peer Teaching Society is not liable for false or misleading information Glomerulonephritis IgA nephropathy Young male with recurrent haematuria after URTI Goodpastures Anti-glomerular basement membrane disease Haemoptysis and haematuria Proliferative GN Post strep infection

Minimal change Common in paeds Rapidly progressive GN ESRF in days The Peer Teaching Society is not liable for false or misleading information Post renal Intraluminal Calculus, clot, sloughed papilla

Intramural Ureteric malignancy, stricture, post raditaion fibrosis, bladder ca, BPH Extrinsic Retroperitoneal fibrosis, pelvic malignancy. The Peer Teaching Society is not liable for false or misleading information Investigation Urine Dipstick: leuks, nitrites, blood, prot*, glucose * Albumin:creatinine to quantify ?osmolality, ?culture Bloods FBC, U+E, LFT, clotting, ESR/CRP

?blood culture, ?ABG, ?Immunology ECG Imaging US 1st line CT ?Renal Biopsy The Peer Teaching Society is not liable for false or misleading information AKI Management TREAT CAUSE Assess fluid status..is the patient dehydrated? Low UO, JVP, poor tissue turgor, low BP, high pulse IV FLUIDS Identify and relieve any obstruction.

Stop nephrotoxic drugs! Dialysis if renal function does not recover The Peer Teaching Society is not liable for false or misleading information Case 1 68 year old male gen unwell fatigue, malaise, N+V, anorexia Started on ramipril for HTN PMH: IHD O/E Bilateral Renal Bruits Differentials? What investigations? Bloods- High urea and creatinine AKI Urine NAD The Peer Teaching Society is not liable for false or misleading information

Case 1 HY PE RK AL AE MI A

Tented T waves Flattened P waves Prolonged PR Wide QRS Sine wave pattern, asystole The Peer Teaching Society is not liable for false or misleading information Case 1 IV Calcium (cardioprotective) 10 ml of 10% Ca gluconate IV IV Insulin + glucose (increases intracellular uptake) Salbutamol nebuliser

Patient potassium stabilises What next? The Peer Teaching Society is not liable for false or misleading information Case 1 Stop ramipril Find and treat cause CT: bilateral renal stenosis, atheromatous changes Refer to vascular stents which improves BP control The Peer Teaching Society is not liable for false or misleading information Chronic Renal Failure

Kidney damage 3/12 based on findings of abnormal kidney structure or function OR GFR<60mL/min/1.73m2 for >3/12 with or without evidence of kidney damage. The Peer Teaching Society is not liable for false or misleading information CKD Classification Stage GFR (mL/min/1.73m2) Notes 1

>90 2 60-89 Slight decrease in GFR + evidence of renal damage 3A 45-59 3B

30-44 Moderate decrease in GFR evidence of renal damage 4 15-29 5 <15 Normal GFR + evidence of renal damage

Severe decrease in GFR evidence of renal damage Established renal failure The Peer Teaching Society is not liable for false or misleading information CKD Classification Evidence of Renal Damage: Persistent microalbuminuria Persistent proteinuria Persistent haematuria Structural Abnormalities of the kidneys by USS eg ADPKD Positive biopsy for chronic glomerulonephritis The Peer Teaching Society is not liable for false or misleading information

CKD Classification Limitations: Validated for patients with established RF Most elderly people are in Stage 3 by eGFR eGFR very dependent on diet Formula less accurate for higher eGFR The Peer Teaching Society is not liable for false or misleading information Aetiology Vascular Infective/Inflamm Trauma AI

Metabolic Iatrogenic/Idiopathic Neoplastic Congenital HTN, Renovascular disease GN SLE, PAN DM Drugs, contrast Myeloma, Renal Ca, Prostate Ca ADPKD, Fabrys, Alports The Peer Teaching Society is not liable for false or misleading information

Clinical Presentation Symptoms N/V, anorexia Peripheral neurpathy Pruritus Lethary Confusion High urea Sx of underlying cause Urinary sx dysuria, increased frequency, nocturia, terminal dribbling SLE rash, arthalgia, dry mouth, pleuritic chest pain The Peer Teaching Society is not liable for false or misleading information

Clinical Presentation Hx PMH DM,IHD. DH NSAIDs FH ADPKD O/E HTN Palpable kidneys Palpable bladder PR- enlarged prostate Renal or femoral

bruits Rash Peripheral Oedema Pallor The Peer Teaching Society is not liable for false or misleading information Investigations Blood FBC, U+E, LFT, Lupus/vasculitis/myeloma screen Urine MC+S, dipstick, ACR Imaging USS CXR, ECG

Renal biopsy: if cause unclear The Peer Teaching Society is not liable for false or misleading information Management Treat reversible causes Obstruction? Avoid Nephrotoxins NSAIDs, Gentamicin, Li, Contrast Treat complications Dialysis/ Transplant The Peer Teaching Society is not liable for false or misleading information

Complications Fl uid overload A cidosis S x of uraemia (fatigue, anorexia, pruritus) H TN B one disease A naemia C VS disease K Hyperkalaemia The Peer Teaching Society is not liable for false or misleading information Renal Osteodystrophy Manifestation of renal disease Pathophysiology: Decreased activation of 1.25 vit D.

Lower Ca abs from gut Increased PTH 2O hyperPTH Increased bone turnover Rugger jersey spine The Peer Teaching Society is not liable for false or misleading information Assessing renal function.. THINK is this ACUTE or CHRONIC? 1.Hx Cormordity = chronic 2.Longstanding decrease in eGFR 3.SIZE OF KIDNEYS usually small in chronic (<9cm) 4.Absence of anaemia, low calcium suggests acute

The Peer Teaching Society is not liable for false or misleading information Lower Urinary Tract Infection Urethritis + Cystitis = symptoms of UTI - Pathophysiology: alkaline urine urine osmolarity micturation volume, commensals - Majority Contamination with bowl flora (E-Coli) The Peer Teaching Society is not liable for false or misleading information Lower Urinary Tract Infection Symptoms

Signs Frequency Haematuria (Microscopic/Macrosc opic) Dysuria Cloudy smelly urine Features suggestive of pyelonephritis = fever, rigors,

loin pain, N&V, guarding and tenderness Suprapubic pain during and after voiding Strangury Differential Diagnosis: -Urethritis (Chlamydia) -Urethral syndrome The Peer Teaching Society is not liable for false or misleading information Lower Urinary Tract Infection Investigations:

Urine dip MSU MC&S If infection is complicated consider U&Es, FBCs and blood cultures The Peer Teaching Society is not liable for false or misleading information Lower Urinary Tract Infection Management: -Increase fluid intake (>2Litres/day) -Trimethoprim 200mg PO BD (3/7) - Alternative Nitrofurantoin

pregnancy) First line antibiotic for LUTI?(inWhat about(PO) in - Ciprofloxacin and co-amoxiclav (PO) pregnancy? The Peer Teaching Society is not liable for false or misleading information Acute Pyelonephritis Loin pain, fever and tender renal angle Nausea, vomitting, (Septic shock) Usually an ascending infection

Complications: perinephric abscesses, papillary necrosis, ureteric obstruction, AKI, The Peer Teaching Society is not liable for false or misleading information Acute Pyelonephritis Differential Diagnosis (Pyelonephritis): -Acute appendicitis -Diverticulitis -Cholecystitis Differential diagnosis -Ruptured ovarian cystof acute pyelonephritis? ALWAYS

consider in -Ectopic pregnancy pre-menopausal women!! The Peer Teaching Society is not liable for false or misleading information Acute Pyelonephritis Investigations: Dipstick MSU MC&S Renal tract USS/CT Investigations for patient with pyelonephritis?

Pelvic examination (women) DRE (men) Blood cultures (if pyrexial) The Peer Teaching Society is not liable for false or misleading information Acute Pyelonephritis Management: ? Hospital admission First line oral antibiotic(PO) treatment? Co-amoxiclav/Ciprofloxacin IV antibiotic treatment regime? OR Gentamycin + Cefuroxime (IV)

Paracetamol Maintain high fluid intake The Peer Teaching Society is not liable for false or misleading information MEQ An 80 year-old man attends his General Practitioner complaining of passing urine very frequently. His symptoms started about 5 years ago and have gradually worsened, so that for the last 12 months he has been passing urine hourly but never felt like his bladder was properly empty. During the last 2 days, he noticed some blood in his urine and felt hot and sweaty. This prompted him to seek medical advice. His GP diagnoses a lower urinary tract infection. 1. From the patients history, what condition may have predisposed to the development of this infection? (2 marks)

The Peer Teaching Society is not liable for false or misleading information MEQ An 80 year-old man attends his General Practitioner complaining of passing urine very frequently. His symptoms started about 5 years ago and have gradually worsened, so that for the last 12 months he has been passing urine hourly but never felt like his bladder was properly empty. During the last 2 days, he noticed some blood in his urine and felt hot and sweaty. This prompted him to seek medical advice. His GP diagnoses a lower urinary tract infection. CHRONIC URINARY RETENTION The Peer Teaching Society is not liable for false or misleading information

MEQ 2. List 4 other symptoms you might enquire about in relation to the patients chronic urinary problems (2 marks) LUTS Nocturia Hesistancy Terminal dribbling Poor urinary stream Intermittent stream Urgency The Peer Teaching Society is not liable for false or misleading information

MEQ 3. List 2 physical signs that you may expect to elicit on abdominal/PR exam (2 marks) Palpable bladder Enlarged prostate Palpable kidney The Peer Teaching Society is not liable for false or misleading information MEQ 4. The patient is referred to a urologist for definitive treatment. In the meantime, a midstream specimen of urine is sent for culture. The results of a gram stain show a gram negative bacillus. List 2 possible pathogens that may be responsible for the patients infection. (2 marks; 1 mark per response)

Escherichia coli (E. coli) Enterobacter Klebsiella sp. Pseudomonas aeruginosa Serratia sp. The Peer Teaching Society is not liable for false or misleading information MEQ 5. The urologist recommends that the patient

undergo an operation to relieve his chronic urinary symptoms. What operation is he most likely to have suggested? (2 marks) TURP (Transurethral resection of prostate) The Peer Teaching Society is not liable for false or misleading information MEQ 2 A 61-year-old man presents to his General Practitioner complaining of increasing difficulty in passing urine. On rectal examination the GP feels an enlarged hard, irregular prostate gland and suspects the diagnosis of carcinoma of the prostate. The patient is referred to the Urology department at the local hospital. State two tests that will aid confirmation of the diagnosis (2)

Transrectal USS Prostatic biopsy Prostate Specific Antigen The Peer Teaching Society is not liable for false or misleading information MEQ 2 The results of these tests confirm prostate cancer. Give two investigations, which will assist in assessing the extent of the disease (2) Transrectal USS CT scan of abdomen (and chest) Alk phosphatase Serum Calcium Isotope bone scan Plain radiographs of axial skeleton

The Peer Teaching Society is not liable for false or misleading information MEQ 2 State 3 treatments that may be used in this condition (3) Prostate surgery Radiotherapy Anti-androgen therapy Orchiectomy The Peer Teaching Society is not liable for false or misleading information MEQBonus question! Treatment is conducted and the GP manages his subsequent

follow up care. Three months later the patient becomes increasingly unwell. He complains increased thirst and has also noticed increased urinary frequency. He has become markedly constipated and his wife says that he is has become far less mentally sharp than he had been previously. The GP arranges admission to hospital. What is the most likely cause of these new symptoms? (1) HYPERCALCAEMIA (?bony mets) The Peer Teaching Society is not liable for false or misleading information EMQ

a. b. c. d. e. Amoxicillin f. Flucoxacillin Antibiotic treatment is not indicated Ceftazidime h. Nitrofurantoin Cephalexin i. Trimethoprim Ciprofloxacinj. Vancomycin

g. Gentamicin A 23-year-old woman presents to her GP with a 2-day history of urinary frequency and dysuria. Her last menstrual period was six weeks previously. She reports that she experienced facial swelling and wheezing when she was given either penicillins or cephalosporins as a teenager. Microscopy of her urine shows numerous white and red blood cells. Culture yields >10 5 /ml of a fully sensitive Escherichia coli. H The Peer Teaching Society is not liable for false or misleading information EMQ

a. b. c. d. e. Amoxicillin f. Flucoxacillin Antibiotic treatment is not indicated Ceftazidime h. Nitrofurantoin

Cephalexin i. Trimethoprim Ciprofloxacin j. Vancomycin g. Gentamicin A 60-year-old man is admitted with a fever. He has had repeated hospital admissions over the preceding year for an unrelated condition, and is known to carry MRSA in his nose. On taking a history, he describes recent onset urinary frequency, nocturia and loin pain. An MSU is sent to the laboratory. Microscopy shows numerous white blood cells and a culture yields >10 5 /ml of Staphylococcus aureus. This morning he has become hypotensive and confused. J

The Peer Teaching Society is not liable for false or misleading information EMQ a. b. c. d.

e. Amoxicillin Antibiotic treatment is not indicated Ceftazidime Cephalexin Ciprofloxacin f. g. h. i. j. Flucoxacillin

Gentamicin Nitrofurantoin Trimethoprim Vancomycin On admission to a residential home, a urine sample is sent from a 75-yearold man with a long-standing indwelling urinary catheter, because it looks cloudy and contains protein on dipstick. The patient is otherwise well. The culture yields >105 /ml of a Pseudomonas aeruginosa sensitive to standard antipseudomonal antibiotics. B The Peer Teaching Society is not liable for false or misleading information

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