1 Urology Phase 2 Kate McDonald and Rebecca MarlorThe 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 CancerUrinary 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 HyperplasiaDefinitions: BPH: Benign prostatic hyperplasia (histological) BPE: Benign prostatic enlargement (DRE) BPO: Benign prostatic obstruction Histological definitieion, cell hyperplasia and reduced apoptosis The Peer Teaching Society is not liable for false or misleading information…

5 Benign Prostatic HyperplasiaCommon 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 Present in all men >40 years old, 75% of >80s Hyperplasia is testosterone dependent, it is thought to respond to a elevated oestrogen:androgen ratio Hyperplastic central cells displace the peripheral cells forming the pseudo-capsule, this can also exert pressure on the urethra. Often the size of the prostate does not correlate with the severity of symptoms. Benign prostatic obstruction = smooth muscle contraction and partial obstriction The Peer Teaching Society is not liable for false or misleading information…

6 Benign Prostatic ObstructionSymptoms Signs Storage symptoms Frequency Smooth enlarged prostate on DRE, Palpable median sulcus Urgency Nocturia Overflow incontinence Voiding Terminal dribbling Difficult initiation Poor flow/straining Hesitancy Inadequate emptying of bladder Usually present with LUTS (lower urinary tract symptoms) = storage, voiding and post-micturation symptoms. Can also get noctural enuresis, spraying. Symptoms such as haematuria, backpain and weight loss are red flags and suggestive of other pathology. Examination = DRE + abdominal examination + external genitalia + (neurological assessment if considering acute retention). May also get recurrent infections due to obstruction (DRE= anal tone, prostate size and consistency (texture and contour)) Also need to ask about fitness for surgery, think about co-morbidities and suitablility for anaesthesia IPSS standardises patient symptoms and assesses QOL, guiding treatment and intervention: <7 = mild and >20 = significant symptoms The Peer Teaching Society is not liable for false or misleading information…

7 Benign Prostatic ObstructionDifferential Diagnosis: Prostate Cancer Urinary bladder Cancer Bladder stone Urethral stricture Prostatitis Detrusor overactivity Prostate cancer = craggy, hard, nodular DRE + elevated PSA, Bladder Cancer = haematuria, Urethral stricture = box-shaped flow, Prostatitis = tender prostate, overactive bladder = typical history of urgency triggers + incontinence If prostate Ca is the likely primary diagnsosis referral to urologists is necessary immediately The Peer Teaching Society is not liable for false or misleading information…

8 Benign Prostatic ObstructionA man presents with LUTS and you think it is probable he has BPH, what investigations would you want to arrange? Investigations: ? PSA Symptom questionnaire (IPSS) Urinalysis U&Es (Creatinine), FBCs, LFTs International prostate symptoms score examines QOL and requirements for surgery/intervention PSA requires interprettation alongside the examination finding FBC and LFT may help to rule out malignancy, U&Es may show evidence of renal failure – due to back pressure USS can measure the quantity of retained urine, Flexible cystoscopy may help rule out strictures and bladder pathology PSA – a protease responsible for the liquification of semen, it is prostate specific BUT NOT cancer specific, it can be interpretted alongside clinical findings to understand risk of prostate Ca. It is also raised in BPO, UTI, prostatitis, urethral instrumentation. The Peer Teaching Society is not liable for false or misleading information…

9 Benign Prostatic ObstructionManagement: Conservative Watchful waiting Medical Alpha adrenergic antagonists (Doxazosin/Tamsulosin) 5-alpha reductase inhibitors (Finasteride) Surgical TURP/prostatectomy Alpha adrenergic receptor = relaxation of internal urethral sphincter (Lower resistance and increased bladder outflow), side effects: reduced BP (also cause vasodilation), dizziness, headaches. Interact with blood pressure medications (B blockers and Ca channel antagonists) Alpha blockers are suitable for moderate to severe LUTS, however in those with significantly enlarged prostates (>30g or PSA>1.4) at risk of transformation it may be appropriate to use a 5 alpha reductase inhibitor aswell (finasteride) The Peer Teaching Society is not liable for false or misleading information…

10 What are the different causes?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 Neurological problems (cord compression) S2-4 Urethral pathology = paraphimosis, stenosis May be precipitated by anticholinergic drugs (eg. Atropine etc….), post-surgery (UT/clot retention) or prolonged suppression of micturation Pain can also cause retention The Peer Teaching Society is not liable for false or misleading information…

11 Upper and lower limb Power/reflexes/Acute Urinary Retention!! Symptoms Signs SUDDEN Inability to pass urine Bladder palpable and distended Supra-pubic pain Tender supra-pubicly Enlarged prostate Agitation EMERGENCY! Check for neurological deficits!! Don’t measure PSA Catheterization Urine output ? Surgery Anal tone Saddle anesthesia Upper and lower limb Power/reflexes/ May be precipitated by anticholinergic drugs, surgery (UT) or prolonged suppression of micturation Prostate may feel large, since full bladder pushes prostate down – making it feel bigger than it is Supra-pubic or urethral catheter can be used, often retaining up to a litre of urine. Should immediately be carried out. Monitor urine output (with input/output sheet), those who re-retain may require medical therapy or surgery (TURP). Trial without. The Peer Teaching Society is not liable for false or misleading information…

12 What serious complications do we worry about?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? On USS >1litre retained urine in the bladder or a palpable percussible bladder CRF = post renal causation, monitor Creatanine for evidence of renal failure 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 Monitor U&Es and urinary proteins/creatanine for evidence of secondary renal failure Intermittent catheterisation may be appropriate for some patients If symptoms are bothersome, these patients are candidate for surgery – voiding (TURP) or storage (cystoplasty/botox unjections). Those with impared renal function are not appropriate for surgery. The Peer Teaching Society is not liable for false or misleading information…

14 Prostate Cancer: Most common male cancerHormonally driven - dihydrogentestosterone Adenocarcinoma, peripheral, ?multi-focal Localized Locally advanced Metastatic By 80 years old 80% have prostate cancer, Risk factors: increasing age, black african/carribean origin, family hx of prostate Ca, diet, obesity, smoking, increasing PSA concentration If a first degree relative has history, at 2x greater risk of prostate Ca over lifetime Localized – typically assymptomatic, as occurs in the peripheral zone – hence less likely to present with LUTS than BPH Locally advanced (spread beyond the prostate capsule), may present with features of rectal, seminal vesicle and bladder involvement, pelvic lymph nodes Metastatic – typically to the bone (sclerotic lesions), brain, lung and liver The Peer Teaching Society is not liable for false or misleading information…

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16 Asymmetrical nodular enlargement of the prostateProstate Cancer Symptoms ? LUTS Acute urinary retention Back/perineal or testicular pain Haematuria Stress incontinence ? Constipation, leg swelling Weight loss Anorexia Fatigue ?Bone pain + pathological fractures What would you expect to find on DRE? DRE: Asymmetrical nodular enlargement of the prostate “Hard and Craggy” Loss of median sulcus Less likely to present with LUTS as prostate Ca effects the peripheral zone – i.e. further away from the urethra. Could also be evidence of weight loss, anaemia etc… The Peer Teaching Society is not liable for false or misleading information…

17 Prostate Cancer: Investigations: PSA TRUS +/- biopsy ?MRI/CT scan? Isototope bone scan Gleason Grading and Clinical Staging On the grounds of the PSA and DRE findings it should be decided by the urologist whether a TRUS with biopsy is necessary, if there is already evidence of bony metastases there is no need for biopsy for histological grading Biopsy can be used to determine GLEASON GRADING (the two most common histological grades are added together) -> higher score is more aggressive. Based on cellular differentiation. Gleason 3+ = cancer. Gleason <6 non aggressive cancer, Gleason >8 = aggressive cancer. Negative biopsy does not mean no prostate cancer!! Still at the same risk! Clinical staging: T1= local unpalpable, T2 = local and palpable, (T1c = PSA found, not clinically detectable), T3/4 = extending beyond the prostate Interprettation of the gleason grading and clinical staging helps to determine the risk of progression and the therapy recommended The Peer Teaching Society is not liable for false or misleading information…

18 Prostate Cancer 70% with moderately elevated PSA have prostate Ca, 6% of those with prostate cancer have elevated PSA PSA is a prostate specific enzyme associated with liquefaction of semen If PSA > % have prostate cancer, The incidence of prostate cancer has increased as a result of PSA screening, reducing metastatic prostate cancer – early intervention The Peer Teaching Society is not liable for false or misleading information…

19 Prostate Cancer Management: Localised Prostate Cancer Watch and waitActive follow up Radical prostatectomy Radiotherapy (brachytherapy/external beam) Focal therapy Localised prostate cancer = 70% survive 10-15years without treatment, confined within the prostate capsule Watch and wait for those whose life expectency is <10 years and a non-aggressive tumour Active follow up = regular DRE, PSA. Aims to treat those who will most benefit. May re-biopsy at a later point in time. Low or intermediate risk prostate cancer Radical prostatectomy = removal of prostate and seminal vessels. Complications are erectile dysfunction (50%) and incontinence Radical radiotherapy = cystitis, prostatitis and erectile dysfunction Brachytherapy- trans rectal implantation of radioactive seeds The radical therapies are reserved for those with high risk prostate cancer. Hormone therapies are now being used more frequently The Peer Teaching Society is not liable for false or misleading information…

20 Prostate Cancer Management: Locally advanced Prostate CancerNeoadjuvent hormonal therapy LHRH Agonists (Goserelin injections): hot flushes, lethargy, loss of sexual function Anti-Androgens: gynaecomastia, nipple tenderness, sometimes retain sexual function Radiotherapy Incurable and therefore palliative Hormonal dependent tumours (80%), Median survival 7 years Hormonal therapy (LHRH agonists) initially result in a rise in testosterone, HOWEVER with chronic administration testosterone is reduced. This is due to suppression of LH and FSH. The flares are prevented by preventing testosterone entering the cell (anti-androgen). Flares usually happen in the first month of therapy – could present with acute retention/spinal cord compression etc… Can take months to see benefits of hormonal therapy Can develop hormonal resistant disease, prognosis is poor from this point and chemo is potentially only useful treatment If recurrence occurs treatment is limited, salvage prostatectomy, pelvic radiotherapy/brachytherapy The Peer Teaching Society is not liable for false or misleading information…

21 Prostate Cancer Management: Metastatic Prostate Cancer:Hormonal therapies Chemotherapy/radiotherapy to improve symptoms and disease control Bisphosphonates Median survival 2-3 years, tumours can become hormone resistant over time Bisphosphonates can help with pain associated with spinal metastases The Peer Teaching Society is not liable for false or misleading information…

22 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…

23 eGFR Estimated Glomerular Filtration RateBased 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…

24 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…

25 AKIN Classification Stage Serum Creatinine UO criteria 1Increase > 26µmol/L within 48 hours or increase > X reference creatinine <0.5mL/kg/hr for >6 hours 2 Increase > 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…

26 AKI Aetiology RENAL PRE RENAL POST RENALThe Peer Teaching Society is not liable for false or misleading information…

27 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…

28 Answers Pre Renal Renal Post Renal B D A C G E F H IThe Peer Teaching Society is not liable for false or misleading information…

29 Pre renal COMMONEST CAUSE OF AKI Decreased intravascular volumeHaemorrhage, shock, burns, D+V Decreased effective circ volume CCF, cirrhosis Drugs ACE, ARB, NSAIDs Renal artery stenosis NSAIDs – block prostaglandins which usually dilate aff arteriole. Ang II leads to constriction of eff arteriole. So ACE blocks Ang mediated constriction leading to dilatation which decreases GFR The Peer Teaching Society is not liable for false or misleading information…

30 Renal Acute Tubular necrosis (ATN) Secondary to hypoperfusion/toxinRed 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…

31 Glomerulonephritis IgA nephropathyYoung 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 Classified histologically The Peer Teaching Society is not liable for false or misleading information…

32 Post renal Intraluminal Intramural ExtrinsicCalculus, 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…

33 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…

34 AKI Management TREAT CAUSEAssess 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…

35 Case 1 68 year old male gen unwell – fatigue, malaise, N+V, anorexiaStarted 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…

36 Case 1 HYPERKALAEMIA Tented T waves Flattened P waves Prolonged PRWide QRS Sine wave pattern, asystole The Peer Teaching Society is not liable for false or misleading information…

37 Case 1 Patient potassium stabilises What next?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…

38 Case 1 Stop ramipril Find and treat causeCT: 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…

39 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…

40 CKD Classification Stage GFR (mL/min/1.73m2) Notes 1 >90Normal GFR + evidence of renal damage 2 60-89 Slight decrease in GFR + evidence of renal damage 3A 45-59 Moderate decrease in GFR ± evidence of renal damage 3B 30-44 4 15-29 Severe decrease in GFR ± evidence of renal damage 5 <15 Established renal failure The Peer Teaching Society is not liable for false or misleading information…

41 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…

42 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…

43 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…

44 Clinical PresentationSymptoms 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…

45 Clinical PresentationHx 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…

46 Investigations Blood FBC, U+E, LFT, Lupus/vasculitis/myeloma screenUrine 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…

47 Management Treat reversible causes Avoid NephrotoxinsObstruction? Avoid Nephrotoxins NSAIDs, Gentamicin, Li, Contrast Treat complications Dialysis/ Transplant The Peer Teaching Society is not liable for false or misleading information…

48 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 Lifestyle advice Reduce Na input – decreases BP and oedema BP Target <140/85 CVS Statins, aspirin Anaemia Exclude IDA. Consider Epo Oedema Loop diuretics and fluid/Na restriction The Peer Teaching Society is not liable for false or misleading information…

49 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…

50 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…

51 Lower Urinary Tract InfectionUrethritis + Cystitis = symptoms of ‘UTI’ Pathophysiology: alkaline urine urine osmolarity micturation volume,  commensals - Majority Contamination with bowl flora (E-Coli) Males most likely to get UTI 60 + or in early life, can complicate bladder obstruction Risk factors: female, age, frequent intercourse, urethral instrumentation, medical conditions Medical conditions increasing the risk of UTI include: bladder outflow obstruction (BPH/Prostate Ca), uterine prolapse (incomplete bladder emptying), neurological problems, foreign bodies, loss of host defenses (DM, atrophic vaginitis and urethritis), stones Majority are caused by bowel flora contamination (Ecoli) – particularly in women – who have a short urethra and wipe their bottom Usually are Ecoli but can also be caused by klebsiella, enterococci, pseudomonas, staph aureus, GBS The Peer Teaching Society is not liable for false or misleading information…

52 Lower Urinary Tract InfectionSymptoms Signs Frequency Haematuria (Microscopic/Macroscopic) Dysuria Cloudy smelly urine Suprapubic pain during and after voiding Strangury Features suggestive of pyelonephritis = fever, rigors, loin pain, N&V, guarding and tenderness Differential Diagnosis: Urethritis (Chlamydia) Urethral syndrome Strangury – intense desire to pass more urine after micturation – due to spasm of inflamed bladder wall Prostatitis typically presents with perineal and suprapubic pain, pain on ejaculation, prosatic tenderness on DRE The Peer Teaching Society is not liable for false or misleading information…

53 Lower Urinary Tract InfectionInvestigations: Urine dip MSU MC&S If infection is complicated consider U&Es, FBCs and blood cultures In children with recurrent UTIs you may wish to image the UT to check for congenital malformations such as Vesicoureteric reflux Complicated UTI = diabetes, ?stone or in Males Bacteria reduced nitrates to nitrites, leukocytes increase likelihood of infection On Microscopy they look for evidence of epithelium, red cells and white cells. MSU – analysis – you can also send the sample off to the lab for more accurate analysis: Bacteria of greater than 105 in the urine allows for diagnosis Bacteria of greater than 102 in the presence of pyuria allows for diagnosis The Peer Teaching Society is not liable for false or misleading information…

54 Lower Urinary Tract InfectionManagement: Increase fluid intake (>2Litres/day) Trimethoprim – 200mg PO BD (3/7) Alternative Nitrofurantoin (in pregnancy) (PO) Ciprofloxacin and co-amoxiclav (PO) First line antibiotic for LUTI? What about in pregnancy? Wiping in the appropriate way, pre/post-coital urination, personal hygeine measures, Don’t recommend cranberry juice – not shown to be efficacious 3 day treatment in women and 7 days in men (or complicated women) Trimethoprim generally should not be given during pregnancy as is an anti-folate preventing DNA synthesis, this can cause neural tube defects if given in the first trimester of pregnancy. Generally avoid!! If co-amoxiclav MCS must show the organism is not resistant to the antibiotics. Further infection is required if male, frequent female UTIs, atypical organisms, childhood, persistant haematuria The Peer Teaching Society is not liable for false or misleading information…

55 Acute Pyelonephritis Loin pain, fever and tender renal angleNausea, vomitting, (Septic shock) Usually an ascending infection Complications: perinephric abscesses, papillary necrosis, ureteric obstruction, AKI, Infection of the renal pelvis and parenchyma, Perinephric abscesses rare – fascilitated by renal scarring and diseae, staph aureus Papillary necrosis = breaking up of kidney tissue, passed per urethra can result in kidney scarring Necrotising (Emphysematous pyelonephritis) can occur in Diabetic patients – associated with gas formation The Peer Teaching Society is not liable for false or misleading information…

56 ALWAYS consider in pre-menopausal women!!Acute Pyelonephritis Differential Diagnosis (Pyelonephritis): Acute appendicitis Diverticulitis Cholecystitis Ruptured ovarian cyst Ectopic pregnancy Differential diagnosis of acute pyelonephritis? ALWAYS consider in pre-menopausal women!! The Peer Teaching Society is not liable for false or misleading information…

57 Investigations for patient with pyelonephritis?Acute Pyelonephritis Investigations: Dipstick MSU MC&S Renal tract USS/CT Pelvic examination (women) DRE (men) Blood cultures (if pyrexial) Investigations for patient with pyelonephritis? MSU MC&S should be done before start of antibiotics The Peer Teaching Society is not liable for false or misleading information…

58 Acute Pyelonephritis Management: ? Hospital admissionCo-amoxiclav/Ciprofloxacin (PO) OR Gentamycin + Cefuroxime (IV) Paracetamol Maintain high fluid intake First line oral antibiotic treatment? IV antibiotic treatment regime? Hospital admission depends on health, comorbidites and age. Not all patients are managed in secondary care. Consider admitting people who are able to take oral fluids and medications if they are pyrexial and have a risk factor for developing a complication. In the absence of any widely accepted admission criteria, clinical judgement on when to admit is required. A low threshold is required for people with: Immunocompromise, for example due to immunosuppressant drug use, cancer, cancer therapies, or AIDS. A foreign body within the renal tract, including renal stones and ureteric or nephrostomy catheters. Abnormalities of renal tract anatomy or function, including vesico–ureteric reflux and polycystic kidney disease. Diabetes mellitus. Renal impairment. Advanced age. Non-pregnancy women, males and people with catheters = cipro/coamoxiclav, these both have action on both gram positive and gram negative bacteria The Peer Teaching Society is not liable for false or misleading information…

59 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…

60 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…

61 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…

62 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…

63 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…

64 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…

65 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…

66 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…

67 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…

68 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…

69 EMQ H a. Amoxicillin f. Flucoxacillinb. Antibiotic treatment is not indicated g. Gentamicin c. Ceftazidime h. Nitrofurantoin d. Cephalexin i. Trimethoprim e. Ciprofloxacin j. 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…

70 EMQ a. Amoxicillin f. Flucoxacillinb. Antibiotic treatment is not indicated g. Gentamicin c. Ceftazidime h. Nitrofurantoin d. Cephalexin i. Trimethoprim e. Ciprofloxacin j. 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…

71 EMQ a. Amoxicillin f. Flucoxacillinb. Antibiotic treatment is not indicated g. Gentamicin c. Ceftazidime h. Nitrofurantoin d. Cephalexin i. Trimethoprim e. Ciprofloxacin j. Vancomycin On admission to a residential home, a urine sample is sent from a 75-year-old 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…