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Urology. 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.

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Phase 2 Kate McDonald and Rebecca Marlor


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    1. Urology Phase 2 Kate McDonald and Rebecca Marlor The Peer Teaching Society is not liable for false or misleading information…

    2. 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…

    3. 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…

    4. 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…

    5. 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…

    6. Benign Prostatic Obstruction The Peer Teaching Society is not liable for false or misleading information…

    7. 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…

    8. Benign Prostatic Obstruction Investigations: • ? PSA • Symptom questionnaire (IPSS) • Urinalysis • U&Es (Creatinine), FBCs, LFTs • A man presents with LUTS and you think it is probable he has BPH, what investigations would you want to arrange? The Peer Teaching Society is not liable for false or misleading information…

    9. 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…

    10. Acute Urinary Retention!! • 67 year old gentleman presents with 24/24 inability to pass urine (anuria) and 12/24 supra-pubic abdominal pain? You suspect he has acute urinary retention? • What are the different causes? Causes: • Benign Prostatic Hyperplasia • Prostate cancer • Prostatitis • Neurological (disc rupture/metastasis) • Urethral pathology • Pelvic mass lesions/constipation • Anticholinergic drugs The Peer Teaching Society is not liable for false or misleading information…

    11. Acute Urinary Retention!! • EMERGENCY! • Check for neurological deficits!! • Don’tmeasure PSA • Catheterization • Urine output • ? Surgery Anal tone Saddle anesthesia Upper and lower limb Power/reflexes/ The Peer Teaching Society is not liable for false or misleading information…

    12. 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…

    13. 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…

    14. 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…

    15. Prostate Cancer • What would you expect to find on DRE? DRE: Asymmetrical nodular enlargement of the prostate “Hard and Craggy” Loss of median sulcus The Peer Teaching Society is not liable for false or misleading information…

    16. 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…

    17. Prostate Cancer The Peer Teaching Society is not liable for false or misleading information…

    18. 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…

    19. 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…

    20. 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…

    21. 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…

    22. 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…

    23. 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…

    24. AKIN Classification The Peer Teaching Society is not liable for false or misleading information…

    25. AKI Aetiology RENAL PRE RENAL POST RENAL The Peer Teaching Society is not liable for false or misleading information…

    26. 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…

    27. Answers The Peer Teaching Society is not liable for false or misleading information…

    28. Pre renal • COMMONESTCAUSE 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…

    29. 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…

    30. 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…

    31. 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…

    32. 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…

    33. 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…

    34. 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…

    35. Case 1 HYPERKALAEMIA • 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…

    36. 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…

    37. 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…

    38. 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…

    39. CKD Classification The Peer Teaching Society is not liable for false or misleading information…

    40. 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…

    41. 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…

    42. Aetiology Vascular HTN, Renovascular disease Infective/Inflamm GN Trauma AI SLE, PAN Metabolic DM Iatrogenic/Idiopathic Drugs, contrast Neoplastic Myeloma, Renal Ca, Prostate Ca Congenital ADPKD, Fabrys, Alports The Peer Teaching Society is not liable for false or misleading information…

    43. Clinical Presentation Symptoms • N/V, anorexia • Peripheral neurpathy High urea • Pruritus • Lethary • Confusion • 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…

    44. 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…

    45. 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…

    46. 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…

    47. 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…

    48. 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…

    49. Assessing renal function….. THINK is this ACUTE or CHRONIC? • Hx – Cormordity = chronic • Longstanding decrease in eGFR • SIZE OF KIDNEYS – usually small in chronic (<9cm) • Absence of anaemia, low calcium suggests acute The Peer Teaching Society is not liable for false or misleading information…