Transcript www.peerteaching.com

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
-probable
Urinalysis
he has BPH, what investigations would
- U&Es (Creatinine),
FBCs,
LFTs
you want
to 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 year old
gentleman presents with 24/24
• Prostate
cancer
to pass urine (anuria) and 12/24 supra•inability
Prostatitis
pubic abdominal pain? You suspect he has acute
• Neurological (disc rupture/metastasis)
urinary retention?
• Urethral pathology
• Pelvic mass
Whatlesions/constipation
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!!
• Don’t 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
chronic
retention do we worry
What on
serious
complications
• Hydronephrosis +about?
bladder hypertrophy ->
chronic renal failure
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
DRE:
Asymmetrical
nodular
What
would
you
enlargement of the prostate
expect to find on
“Hard and Craggy”
DRE?
Loss of median sulcus
Weight loss
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
equation……Modification 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 > 26µmol/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 > 26µmol/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
PRE RENAL, RENAL
E: Renal calculi
or POST RENAL???
F: ACE inhibitor
G: Acute Tubular Necrosis
H: NSAIDs
I: Renal Artery Stenosis
J :BPH 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
•
•
•
•
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
diagnosis
of acute pyelonephritis?
- Differential
Ruptured ovarian
cyst
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
treatment?
•Co-amoxiclav/Ciprofloxacin
(PO)
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 patient’s 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 patient’s 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…
MEQ…Bonus 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
Antibiotic treatment is not indicated
Ceftazidime
Cephalexin
Ciprofloxacin
f.
g.
h.
i.
j.
Flucoxacillin
Gentamicin
Nitrofurantoin
Trimethoprim
Vancomycin
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 >105 /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
Antibiotic treatment is not indicated
Ceftazidime
Cephalexin
Ciprofloxacin
f.
g.
h.
i.
j.
Flucoxacillin
Gentamicin
Nitrofurantoin
Trimethoprim
Vancomycin
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 >105 /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…