30 types of urine system disease kidney urine bladder prostrate most important disease treatment investigation finding differential diagnosis contraindication ICO management OPD prescription

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Finding Sources

The library confirms excellent nephrology and urology sources. Drawing on the confirmed textbooks (Brenner & Rector's The Kidney, Comprehensive Clinical Nephrology 7e, Campbell-Walsh Urology, Goldman-Cecil Medicine, Harrison's, NKF Primer, Robbins Pathology), here is the comprehensive reference:

30 Urinary System Diseases — Clinical Reference

KIDNEY DISEASES

1. ACUTE KIDNEY INJURY (AKI)

Definition: Sudden decline in renal function (↑Creatinine ≥0.3 mg/dL in 48h or ↑50% in 7 days, or UO <0.5 mL/kg/hr for 6h).

Classification: Pre-renal | Intrinsic (ATN, GN, AIN) | Post-renal

Investigations:

Serum Cr, BUN, eGFR, electrolytes, ABG
Urine: dipstick, microscopy (muddy brown casts = ATN), Na, FENa, osmolality
Renal USS (obstruction, size)
FENa: <1% = pre-renal; >2% = intrinsic ATN

Key Findings:

Oliguria/anuria, oedema, hypertension
Hyperkalaemia, metabolic acidosis, hyperphosphataemia
BUN:Cr ratio >20:1 → pre-renal

Differential Diagnosis: CKD, pre-renal azotaemia, obstructive uropathy, HRS

Treatment/Management:

Remove precipitant; IV fluids (pre-renal)
Loop diuretics (volume overload)
Treat hyperkalaemia (calcium gluconate, insulin+dextrose, salbutamol, kayexalate)
Dialysis (AEIOU criteria: Acidosis, Electrolytes, Intoxication, Overload, Uraemia)
Avoid nephrotoxins (NSAIDs, aminoglycosides, contrast)

OPD Prescription:

Furosemide 40 mg BD PO (if fluid overloaded)
Sodium bicarbonate 500 mg TDS (acidosis)
Monitor U&E twice weekly

Contraindications: ACEi/ARBs in bilateral RAS; NSAIDs; IV contrast without hydration

2. CHRONIC KIDNEY DISEASE (CKD)

Definition: GFR <60 mL/min/1.73m² or kidney damage markers for >3 months.

Stages: G1 (≥90) → G5 (<15) | Albuminuria: A1-A3

Investigations:

eGFR (CKD-EPI), urine ACR, 24-hr urine protein
Renal USS: small, echogenic kidneys
Renal biopsy (if unclear aetiology)
FBC (normocytic anaemia), PTH, phosphate, Ca, Vit D, bicarbonate

Key Findings:

Uraemic symptoms: fatigue, nausea, pruritus, uraemic frost
Anaemia, renal osteodystrophy, CKD-mineral bone disease
Hypertension, fluid retention

Differential: Diabetic nephropathy, HTN nephrosclerosis, renovascular disease, ADPKD

Treatment:

BP control: ACEi/ARB (target <130/80)
SGLT2 inhibitors (dapagliflozin — CKD G3-G4 with proteinuria)
Anaemia: EPO + IV iron (target Hb 10-12 g/dL)
Phosphate binders (sevelamer), Vit D analogue (alfacalcidol)
Low-protein diet (0.6-0.8 g/kg/day)
Dialysis/transplant at G5

OPD Prescription:

Ramipril 5 mg OD (or losartan 50 mg OD)
Dapagliflozin 10 mg OD
Ferrous sulphate 200 mg TDS
Calcium carbonate 500 mg with meals (phosphate binder)
Alfacalcidol 0.25 mcg OD

Contraindications: Metformin if eGFR <30; NSAIDs; high-K+ diet with ACEi

3. NEPHROTIC SYNDROME

Definition: Proteinuria >3.5 g/day + hypoalbuminaemia + oedema + hyperlipidaemia.

Causes: MCD (children), FSGS, MN, diabetic nephropathy, amyloidosis, lupus

Investigations:

24-hr urine protein or spot urine PCR >300 mg/mmol
Serum albumin <25 g/L
Fasting lipids (hypercholesterolaemia), LFT
Complement (C3/C4 low in SLE, MPGN)
Renal biopsy (essential in adults)
ANA, anti-dsDNA, SPEP, hepatitis B/C, HIV

Key Findings:

Pitting oedema (periorbital initially in children)
Frothy urine, lipiduria (Maltese cross on polarised)
Oval fat bodies on urinary microscopy

Differential: Cirrhosis, CCF, protein-losing enteropathy, nephritic syndrome

Treatment:

MCD: Prednisolone 1 mg/kg/day → taper over 3-6 months
FSGS: Prednisolone; cyclosporine if resistant
MN: KDIGO Ponticelli protocol (steroids + chlorambucil alternating)
Diuretics (furosemide + spironolactone for oedema)
ACEi/ARB (reduce proteinuria)
Statins (dyslipidaemia), anticoagulation (high DVT risk, especially MN)

OPD Prescription:

Prednisolone 60 mg OD (MCD — 4-6 weeks then taper)
Furosemide 40 mg OD
Spironolactone 25 mg OD
Atorvastatin 20 mg nocte
Ramipril 5 mg OD

Contraindications: Live vaccines during immunosuppression; NSAIDs (worsen oedema, AKI risk)

4. NEPHRITIC SYNDROME

Definition: Haematuria (RBC casts), proteinuria <3.5 g/day, hypertension, oliguria, oedema.

Causes: Post-streptococcal GN, IgA nephropathy, lupus nephritis, ANCA vasculitis, anti-GBM disease

Investigations:

Urinalysis: dysmorphic RBCs, RBC casts
ASO titre, anti-DNase B (post-strep)
ANA, anti-dsDNA, ANCA (PR3/MPO), anti-GBM
C3/C4 (low in SLE, post-strep, MPGN)
Renal biopsy (definitive)

Key Findings:

"Cola/tea-coloured" urine, hypertension, oliguria
Light microscopy: hypercellular glomeruli (post-strep); crescents (RPGN)
IF: "lumpy bumpy" granular (post-strep); linear (Goodpasture)

Differential: Nephrotic syndrome, haemorrhagic cystitis, IgA nephropathy, thin basement membrane disease

Treatment:

PSGN: supportive (salt/fluid restriction, antihypertensives, penicillin for active strep)
RPGN (crescentic GN): IV methylprednisolone + cyclophosphamide; plasma exchange (anti-GBM, ANCA)
Lupus nephritis: MMF or cyclophosphamide + steroids
IgA nephropathy: ACEi/ARB, fish oil, steroids if proteinuria >1 g/day

OPD Prescription:

Amlodipine 5 mg OD (BP control)
Ramipril 5 mg OD (proteinuria)
Prednisolone 1 mg/kg/day (when indicated)

Contraindications: Cyclophosphamide in pregnancy; live vaccines

5. IgA NEPHROPATHY (Berger's Disease)

Key Features: Most common primary GN worldwide; episodic gross haematuria with URTI (synpharyngitic haematuria).

Investigations: Renal biopsy — mesangial IgA deposits on IF; raised serum IgA (50%)

Differential: Post-strep GN (delayed haematuria), thin BM disease, Alport syndrome, HSP

Treatment: ACEi/ARB (proteinuria <1 g/day); steroids + fish oil (proteinuria 1-3 g); SGLT2i; Sparsentan (novel DUAL Ang/ET receptor antagonist, FDA 2023)

6. LUPUS NEPHRITIS

Classes (ISN/RPS): I–VI (Class III/IV most severe — proliferative)

Investigations: ANA, anti-dsDNA, anti-Sm, C3/C4 low, renal biopsy, urine PCR

Treatment:

Induction: MMF 3 g/day + prednisolone OR IV cyclophosphamide (NIH protocol)
Maintenance: MMF 2 g/day + low-dose steroid
Hydroxychloroquine (all patients — renoprotective)
Belimumab (adjunctive in active disease)

7. DIABETIC NEPHROPATHY

Stages: Microalbuminuria (ACR 3-30 mg/mmol) → Macroalbuminuria → Declining GFR

Investigations: Annual urine ACR, eGFR, HbA1c, fundoscopy (retinopathy co-exists)

Pathology: Kimmelstiel-Wilson nodules (nodular glomerulosclerosis), GBM thickening

Treatment: Tight glycaemic control (HbA1c <53 mmol/mol); ACEi/ARB; SGLT2i (empagliflozin, dapagliflozin); Finerenone (novel MRA — reduces CKD progression in DM)

Contraindications: SGLT2i if eGFR <20; Metformin if eGFR <30

8. HYPERTENSIVE NEPHROSCLEROSIS

Features: Long-standing HTN → afferent arteriolar thickening → nephron loss; mild proteinuria, slowly declining eGFR

Investigations: Renal USS (mildly small, echogenic), bland urinalysis, normal C3/C4

Treatment: BP target <130/80; ACEi/ARB first-line; low-salt diet

9. POLYCYSTIC KIDNEY DISEASE (ADPKD)

Gene: PKD1 (85%, chr 16), PKD2 (15%, chr 4)

Features: Bilateral multiple renal cysts, HTN, haematuria, abdominal mass, flank pain, recurrent UTI, renal calculi

Extra-renal: Hepatic cysts, intracranial berry aneurysms, mitral valve prolapse

Investigations: USS (>2 cysts per kidney in <30 yrs, >4 cysts per kidney in >60 yrs); MRI; genetic testing (PKD1/2)

Differential: Simple renal cysts, tuberous sclerosis, von Hippel-Lindau

Treatment: Tolvaptan (V2 receptor antagonist — slows cyst growth; licensed if rapidly progressive, Toronto class 1C-E); ACEi/ARB; analgesics; treat complications; dialysis/transplant

Contraindications: Tolvaptan — hepatotoxicity risk (monitor LFTs monthly for 18 months); avoid nephrotoxins

10. RENAL TUBULAR ACIDOSIS (RTA)

Types:

Type	Defect	Urine pH	Serum K+
1 (Distal)	H+ secretion failure	>5.5	Low
2 (Proximal)	HCO3 reabsorption failure	<5.5	Low
4	Aldosterone deficiency/resistance	<5.5	High

Causes: Sjogren's, SLE, medullary sponge kidney (Type 1); Wilson's, Fanconi (Type 2); DM, CAH (Type 4)

Investigations: ABG (NAGMA), urine pH, serum electrolytes, urine anion gap (positive = distal RTA)

Treatment: Sodium bicarbonate (Type 1 & 2); fludrocortisone (Type 4); potassium citrate (nephrolithiasis)

11. ACUTE TUBULAR NECROSIS (ATN)

Causes: Ischaemia (post-shock, sepsis), nephrotoxins (aminoglycosides, cisplatin, contrast, myoglobin)

Investigations: Muddy brown granular casts, FENa >2%, renal USS (normal size)

Phases: Initiation → Oliguric (1-3 wks) → Polyuric (diuresis phase) → Recovery

Treatment: Supportive — fluid management, avoid nephrotoxins, dialysis if needed; N-acetylcysteine (prevention of contrast nephropathy)

12. INTERSTITIAL NEPHRITIS (AIN)

Causes: Drug-induced (NSAIDs, PPIs, penicillins, sulfonamides), infections, autoimmune (Sarcoid, SLE, Sjogren's)

Investigations: Urine eosinophils (unreliable); eosinophilia; raised Cr; renal biopsy (interstitial inflammation + eosinophils)

Treatment: Stop offending drug; prednisolone 1 mg/kg/day if severe or no improvement at 2 weeks

13. RENOVASCULAR DISEASE / RENAL ARTERY STENOSIS

Causes: Atherosclerosis (elderly), fibromuscular dysplasia (young women)

Features: Resistant hypertension, flash pulmonary oedema, deterioration with ACEi/ARB

Investigations: Duplex USS (screening); CT angiography or MR angiography (gold standard); captopril renogram

Treatment: Medical (ACEi/ARB — caution bilateral); percutaneous transluminal angioplasty ± stenting (FMD); revascularisation (atherosclerotic — limited evidence)

Contraindications: ACEi/ARB absolutely contraindicated in bilateral RAS (causes AKI)

14. RENAL CALCULI (Nephrolithiasis)

Types: Calcium oxalate (70%), Struvite/triple phosphate (infection), Uric acid, Cystine

Features: Loin-to-groin colicky pain, haematuria, N&V, dysuria

Investigations:

NCCT KUB (gold standard — detects all stones)
USS + KUB X-ray (initial)
Urine dipstick (blood), MSU, serum Ca, urate, oxalate
24-hr urine (Ca, oxalate, uric acid, citrate, volume)

Stone characteristics on X-ray:

Radiopaque: calcium oxalate, calcium phosphate
Radiolucent: uric acid, cystine (semi-opaque)
Staghorn calculus: struvite

Differential: Ureteric colic, appendicitis, ovarian cyst, pyelonephritis, AAA

Treatment:

<5 mm: conservative (fluids, analgesia — diclofenac 75 mg IM/PR, tamsulosin 0.4 mg OD — alpha-blocker MET)
5-10 mm: tamsulosin ± ESWL
10 mm / complex: ESWL, ureteroscopy, PCNL (>2 cm)
Struvite: treat infection + stone removal
Uric acid: urine alkalinisation (potassium citrate), allopurinol
Prevention: high fluid intake >2.5 L/day, low salt, low oxalate diet, thiazide (Ca stones), allopurinol (uric acid)

OPD Prescription:

Diclofenac 50 mg TDS PRN + PPI cover
Tamsulosin 0.4 mg OD (MET)
K-citrate 15 mEq BD (uric acid/cystine stones)

Contraindications: NSAIDs in renal impairment; ESWL in pregnancy, bleeding disorders, distal obstruction, abdominal aortic aneurysm

15. PYELONEPHRITIS

Features: Fever, rigors, loin pain, CVA tenderness, dysuria, frequency

Investigations:

Urinalysis (leucocytes, nitrites, blood)
MSU M&C&S (most important)
Blood cultures (if systemically unwell)
USS/CT (complicated: obstruction, abscess, emphysematous pyelonephritis)
WBC, CRP, procalcitonin

Common Organism: E. coli (80%), Klebsiella, Proteus, Enterococcus

Differential: Appendicitis, cholecystitis, ovarian pathology, diverticulitis, renal colic, perinephric abscess

Treatment:

Uncomplicated (outpatient): Trimethoprim 200 mg BD × 14 days OR ciprofloxacin 500 mg BD × 7 days
Complicated/Inpatient: IV ceftriaxone 1-2 g OD or IV gentamicin (dose-adjust for renal function)
Duration: 7-14 days; 14 days for complicated

OPD Prescription:

Ciprofloxacin 500 mg BD × 7 days (after MSU)
Paracetamol 1 g QDS PRN
Increase oral fluid intake >2 L/day

Contraindications: Fluoroquinolones in children, pregnancy (use cephalosporins); trimethoprim in 1st trimester (folate antagonist)

16. RENAL CELL CARCINOMA (RCC)

Classic Triad: Haematuria + loin pain + flank mass (only 10% — late presentation)

Subtypes: Clear cell (70%), papillary (15%), chromophobe (5%)

Investigations:

CT chest/abdomen/pelvis with contrast (staging + surgical planning)
MRI (IVC involvement)
Renal biopsy (if metastatic — confirm histology before systemic therapy)
Urine cytology (negative — not useful)
Paraneoplastic: polycythaemia, hypercalcaemia, HTN, Stauffer syndrome (liver dysfunction)

Differential: TCC of renal pelvis, oncocytoma, angiomyolipoma, Wilms (children)

Treatment:

Localised: Radical or partial nephrectomy (laparoscopic preferred)
Metastatic: Sunitinib/pazopanib (TKI, 1st line), ipilimumab + nivolumab (IO combination), everolimus (2nd line)
Adjuvant: pembrolizumab post-nephrectomy (high risk)

Contraindications: TKIs — hepatotoxicity; bevacizumab — uncontrolled HTN, bleeding, fistula

17. GLOMERULOSCLEROSIS (FSGS)

Features: Nephrotic syndrome, resistant to steroids in adults; HIV-associated FSGS (collapsing variant)

Biopsy: Focal (some glomeruli) + segmental (part of glomerulus) sclerosis on LM; effacement of foot processes on EM

Treatment: Prednisolone 1 mg/kg/day × 4-6 months; cyclosporine/tacrolimus (steroid-resistant); ACEi/ARB; sparsentan (FDA 2023)

18. MINIMAL CHANGE DISEASE (MCD)

Features: Commonest cause of nephrotic syndrome in children; sudden onset heavy proteinuria; responds to steroids

Biopsy: Normal LM; podocyte foot process effacement on EM; no IF deposits

Treatment: Prednisolone 60 mg/m² OD × 4-6 weeks → taper; levamisole (maintenance, steroid-sparing in children); cyclophosphamide (frequent relapser)

19. MEMBRANOUS NEPHROPATHY (MN)

Features: Commonest cause of nephrotic syndrome in white adults; associated with anti-PLA2R antibody (70%); secondary causes: HBV, malignancy, SLE, drugs (gold, penicillamine)

Biopsy: "Spike and dome" appearance on silver stain; IgG + C3 granular deposits on IF; subepithelial deposits on EM

Treatment: ACEi/ARB + supportive (spontaneous remission 30%); KDIGO modified Ponticelli (steroids + chlorambucil, 6 months) for severe disease; Rituximab (anti-CD20 — increasingly used, non-inferior to Ponticelli)

20. ALPORT SYNDROME

Genetics: X-linked (80%) — COL4A5 mutation; AR — COL4A3/4 mutation

Features: Haematuria (persistent) + SNHL + ocular abnormalities (anterior lenticonus); family history of renal failure

Biopsy: Irregular thinning + thickening of GBM with splitting (basket-weave) on EM; absent type IV collagen on IF

Treatment: ACEi/ARB (delays progression); dialysis/transplant; genetic counselling

BLADDER DISEASES

21. URINARY TRACT INFECTION (LOWER UTI / CYSTITIS)

Features: Dysuria, frequency, urgency, suprapubic pain, cloudy/smelly urine; NO systemic features

Organisms: E. coli (80%), Staphylococcus saprophyticus (young women), Klebsiella

Investigations:

Urine dipstick (nitrites + leucocytes — 85% sensitive)
MSU M&C&S (gold standard; indicated in complicated UTI, pregnancy, recurrent, men, children)

Differential: Urethritis (STI — Chlamydia, Gonorrhoea), interstitial cystitis, overactive bladder, vaginitis, bladder cancer (painless haematuria)

Treatment:

Uncomplicated women: Trimethoprim 200 mg BD × 3 days OR nitrofurantoin 100 mg MR BD × 3 days
Recurrent UTI: Post-coital prophylaxis (nitrofurantoin 50 mg), long-term low-dose prophylaxis, D-mannose
Pregnant: Nitrofurantoin × 7 days (avoid near term); cephalexin 500 mg QDS × 7 days
Men: Ciprofloxacin 500 mg BD × 7 days (exclude prostatitis)

OPD Prescription:

Nitrofurantoin 100 mg MR BD × 3 days (uncomplicated female)
Trimethoprim 200 mg BD × 3 days (alternative)
Paracetamol 1 g QDS + increase fluid intake

Contraindications: Nitrofurantoin — eGFR <30 (ineffective + risk of neuropathy); avoid in late pregnancy (neonatal haemolysis); trimethoprim — 1st trimester, hyperkalaemia risk with ACEi

22. INTERSTITIAL CYSTITIS / BLADDER PAIN SYNDROME

Features: Chronic bladder pain (>6 months), urinary urgency/frequency, sterile urine; predominantly women

Investigations: Cystoscopy + hydrodistension (Hunner lesions), urine cytology (exclude TCC), MSU (exclude infection), urodynamics

Differential: UTI, overactive bladder, bladder cancer, endometriosis, pelvic floor dysfunction

Treatment: Bladder retraining; intravesical instillations (DMSO, hyaluronic acid); pentosan polysulphate sodium (Elmiron) PO; amitriptyline 25-75 mg nocte; cyclosporine A; neuromodulation; cystectomy (last resort)

23. BLADDER CANCER

Risk Factors: Smoking (#1), aniline dyes (occupational), schistosomiasis (SCC), cyclophosphamide, phenacetin

Features: Painless haematuria (frank or microscopic) — "must rule out cancer"

Types: TCC/Urothelial (90%), SCC (Schistosoma), Adenocarcinoma

Staging:

Non-muscle invasive (NMIBC): Ta, T1, CIS
Muscle-invasive (MIBC): T2-T4

Investigations:

Flexible cystoscopy (gold standard)
CT urogram (upper tract assessment)
Urine cytology (high-grade/CIS)
TURBT (transurethral resection — diagnosis + staging)

Differential: UTI, renal calculi, RCC, prostatitis, BPH, ureteric TCC, endometriosis

Treatment:

NMIBC Ta low grade: TURBT ± intravesical mitomycin C (single dose)
NMIBC high grade/CIS/T1: TURBT + BCG immunotherapy × 6 weeks induction + maintenance × 3 years
MIBC T2-T4: Radical cystectomy (neoadjuvant cisplatin-based chemo → gemcitabine + cisplatin)
Metastatic: Cisplatin + gemcitabine; pembrolizumab (2nd line or cisplatin-ineligible); enfortumab vedotin + pembrolizumab (1st line, FDA 2023)

Contraindications: BCG — immunocompromised, active UTI, traumatic catheterisation, TB history; Cisplatin — eGFR <50

24. OVERACTIVE BLADDER (OAB)

Features: Urgency ± urge incontinence + frequency + nocturia; no infection

Investigations: Urine dipstick + MSU (exclude UTI); bladder diary; urodynamics (detrusor overactivity)

Treatment:

Conservative: Bladder retraining, pelvic floor exercises, fluid/caffeine restriction
Pharmacological: Solifenacin 5 mg OD (M3 antagonist) OR mirabegron 50 mg OD (β3-agonist) — preferred if dry mouth/cognition concerns
Intravesical Botox (onabotulinumtoxin A 100 units) — refractory
PTNS (percutaneous tibial nerve stimulation); sacral neuromodulation

Contraindications: Antimuscarinics — narrow-angle glaucoma, urinary retention, GI obstruction, cognitive impairment (elderly); avoid oxybutynin in elderly (anticholinergic burden)

25. NEUROGENIC BLADDER

Causes: Spinal cord injury, MS, Parkinson's, DM autonomic neuropathy, spina bifida

Types: Spastic (upper motor neuron — urgency, small capacity) vs Flaccid (LMN — retention, overflow)

Investigations: Urodynamics (gold standard); USS post-void residual (PVR); MRI spine

Treatment: Clean intermittent catheterisation (CIC — gold standard); antimuscarinics (spasticity); alpha-blockers (outflow); intravesical Botox; sphincterotomy; suprapubic catheter

PROSTATE DISEASES

26. BENIGN PROSTATIC HYPERPLASIA (BPH)

Features: Obstructive: hesitancy, weak stream, terminal dribbling, incomplete emptying; Irritative: frequency, urgency, nocturia; Middle-age+ men

Investigations:

DRE (enlarged, smooth, non-tender — "rubbery")
PSA (to exclude PCa — if PSA raised, consider biopsy)
USS abdomen + post-void residual
IPSS (International Prostate Symptom Score)
Flow rate (urodynamics if uncertain)
Urine dipstick + MSU

Differential: Prostate cancer, prostatitis, urethral stricture, neurogenic bladder, bladder cancer, bladder neck obstruction

Treatment:

Mild (IPSS <8): Watchful waiting + lifestyle (fluid restriction, double voiding)
Alpha-blockers: Tamsulosin 0.4 mg OD (rapid onset, relax smooth muscle) — first-line
5-alpha reductase inhibitors: Finasteride 5 mg OD or dutasteride 0.5 mg OD (shrink gland; for large prostate >40 mL; 6+ month onset)
Combination: Tamsulosin + finasteride (large gland, high PSA, prevention of AUR)
Tadalafil 5 mg OD (if concurrent erectile dysfunction)
Surgery: TURP (gold standard surgical Rx), HoLEP, UroLift, Rezum (steam injection)
Acute urinary retention: Urethral catheter (if fails → suprapubic) → trial without catheter (TWOC) after alpha-blocker

OPD Prescription:

Tamsulosin 0.4 mg OD (MR)
Finasteride 5 mg OD (if prostate >40 mL)
Mirabegron 50 mg OD (if persistent irritative symptoms)

Contraindications: Alpha-blockers — postural hypotension, caution with antihypertensives and PDE5i; 5-ARIs — not in pregnancy (teratogenic — use gloves); PSA halved by 5-ARIs (adjust accordingly)

27. PROSTATE CANCER (PCa)

Features: Often asymptomatic early; LUTS (obstruction), bone pain (metastases — lumbar spine, pelvis), haematuria, haematospermia, erectile dysfunction

Investigations:

PSA (age-adjusted; PSA density, PSA velocity, free:total PSA ratio)
DRE (irregular, hard, asymmetric — "craggy" nodule)
MRI prostate (multi-parametric MRI — PI-RADS score; pre-biopsy staging)
TRUS-guided or MRI-fusion targeted biopsy (diagnosis + Gleason grading)
Bone scan + CT (if PSA >10, Gleason >7, or N/M staging)
Gleason score (2-10) → Grade groups 1-5

Staging: T1-T4 | N0-N1 | M0-M1

Differential: BPH, prostatitis, UTI, bladder cancer, seminal vesicle pathology

Treatment:

Low risk (Gleason 6, PSA <10): Active surveillance (PSA every 6 months, repeat MRI/biopsy)
Intermediate/High risk localised: Radical prostatectomy (RP) OR external beam radiotherapy (EBRT) + ADT × 6-18 months
Locally advanced: EBRT + long-term ADT (2-3 years)
Metastatic hormone-sensitive (mHSPC): ADT (LHRH agonist — leuprorelin/goserelin OR bilateral orchidectomy) + docetaxel OR abiraterone OR darolutamide
Castration-resistant (mCRPC): Abiraterone + prednisolone; enzalutamide; docetaxel; radium-223 (bone mets); PARP inhibitors (olaparib — BRCA mutation)

OPD Prescription (ADT + AR pathway):

Leuprorelin 3.75 mg SC monthly (LHRH agonist) + bicalutamide 50 mg OD (flare cover × 4 wks)
Abiraterone 1000 mg OD + prednisolone 5 mg BD (mCRPC/mHSPC)
Zoledronic acid 4 mg IV 4-weekly (bone protection)
Calcium + Vit D (bone health on ADT)

Contraindications: LHRH agonists — testosterone flare (cover with anti-androgen 1st week); enzalutamide — severe hepatic impairment, seizures; olaparib — concurrent CYP3A4 inhibitors without dose adjustment

28. PROSTATITIS

Types:

Type	Features
I — Acute bacterial	Fever, chills, perineal pain, dysuria, acute ill, DRE tender (do NOT massage!)
II — Chronic bacterial	Recurrent UTI, pelvic/perineal pain, raised PSA
III — Chronic pelvic pain syndrome (CPPS)	Pain >3 months, sterile cultures — most common (95%)
IV — Asymptomatic inflammatory	Incidental finding on biopsy

Investigations:

MSU, blood cultures (Type I)
Meares-Stamey 4-glass test or 2-glass pre/post-prostate massage test (Type II/III)
USS (exclude abscess), PSA (raised acutely)

Differential: BPH, PCa, seminal vesicle cyst, pudendal neuralgia, bladder cancer, STI

Treatment:

Acute bacterial: IV ceftriaxone → ciprofloxacin 500 mg BD × 4-6 weeks
Chronic bacterial: Ciprofloxacin 500 mg BD × 4-6 weeks OR trimethoprim × 12 weeks
CPPS: Alpha-blockers (tamsulosin) + anti-inflammatories + pelvic floor physio + amitriptyline/gabapentin (neuropathic component); 5-ARIs; CBT
Prostatic abscess: TRUS-guided drainage

Contraindications: Prostatic massage in Type I (risk of septicaemia); fluoroquinolones — prolonged QT

29. ERECTILE DYSFUNCTION / PROSTATE-RELATED SEXUAL DYSFUNCTION

Features: Post-RP incontinence + ED; ED in chronic prostatitis; hormonal (post-ADT)

Treatment:

PDE5 inhibitors: Sildenafil 50 mg PRN, tadalafil 5 mg OD (concurrent BPH)
Vacuum erection devices; intracavernosal alprostadil; penile implant
Post-RP: early penile rehabilitation

Contraindications: PDE5i — absolute CI with nitrates (hypotension risk); caution with alpha-blockers

URETERS & COLLECTING SYSTEM

30. VESICOURETERAL REFLUX (VUR)

Definition: Retrograde flow of urine from bladder to ureter/kidney

Grades: I (ureter only) → V (severe — dilated, tortuous ureter + intrarenal reflux)

Features: Recurrent febrile UTI in children; renal scarring → reflux nephropathy → HTN, proteinuria, CKD

Investigations:

Micturating cystourethrogram (MCUG) — gold standard diagnosis
DMSA isotope scan (renal scarring — most sensitive)
USS (dilatation — poor sensitivity for VUR)
MAG3 renogram (function + drainage)

Differential: Duplex collecting system, ureterocele, posterior urethral valves (boys), pelviureteric junction obstruction (PUJ)

Treatment:

Grade I-III: Antibiotic prophylaxis (trimethoprim 2 mg/kg nocte OR nitrofurantoin 1 mg/kg nocte) + surveillance; most resolve spontaneously
Grade IV-V / breakthrough infections / scarring: Endoscopic treatment (STING/HIT procedure — submucosal Deflux injection) OR ureteric reimplantation

Contraindications: Nitrofurantoin prophylaxis — eGFR <30 (ineffective); avoid in infants <3 months (haemolytic anaemia risk)

Quick Reference Summary Table

#	Disease	Key Investigation	First-Line Treatment
1	AKI	FENa, urine casts	Remove cause; fluids; dialysis
2	CKD	eGFR, urine ACR	ACEi/ARB + SGLT2i
3	Nephrotic Syndrome	Renal biopsy	Prednisolone (MCD)
4	Nephritic Syndrome	Renal biopsy, ANCA/ANA	Steroids ± cyclophosphamide
5	IgA Nephropathy	Biopsy (mesangial IgA)	ACEi/ARB; Sparsentan
6	Lupus Nephritis	Anti-dsDNA, C3/C4, biopsy	MMF + steroids
7	Diabetic Nephropathy	Urine ACR, HbA1c	ACEi + SGLT2i + finerenone
8	HTN Nephrosclerosis	USS, bland urine	BP control — ACEi/ARB
9	ADPKD	USS / MRI	Tolvaptan; ACEi
10	RTA	ABG, urine pH, UAG	NaHCO3 (Type 1/2); Fludrocortisone (Type 4)
11	ATN	FENa >2%, muddy casts	Supportive; avoid nephrotoxins
12	AIN	Urine eosinophils, biopsy	Stop drug; prednisolone
13	Renal Artery Stenosis	CT/MR angiography	ACEi (unilateral); angioplasty
14	Renal Calculi	NCCT KUB	Analgesia; MET (tamsulosin); ESWL/PCNL
15	Pyelonephritis	MSU M&C&S	Ciprofloxacin/ceftriaxone
16	RCC	CT CAP	Nephrectomy; sunitinib/IO
17	FSGS	Biopsy (EM foot process effacement)	Prednisolone; cyclosporine
18	MCD	Biopsy (normal LM, EM effacement)	Prednisolone
19	Membranous Nephropathy	Anti-PLA2R, biopsy	Rituximab/Ponticelli
20	Alport Syndrome	EM (basket-weave GBM)	ACEi/ARB; transplant
21	UTI/Cystitis	Urine dipstick + MSU	Nitrofurantoin/trimethoprim × 3 days
22	Interstitial Cystitis	Cystoscopy, Hunner lesions	Amitriptyline; intravesical DMSO
23	Bladder Cancer	Cystoscopy + TURBT	TURBT ± BCG; radical cystectomy
24	Overactive Bladder	Urodynamics	Solifenacin / mirabegron
25	Neurogenic Bladder	Urodynamics	CIC; antimuscarinics
26	BPH	IPSS, PSA, USS PVR	Tamsulosin; finasteride; TURP
27	Prostate Cancer	PSA, mpMRI, biopsy	Active surveillance; RP/RT; ADT
28	Prostatitis	MSU, 4-glass test	Ciprofloxacin × 4-6 weeks
29	ED (prostate-related)	Clinical	PDE5i (sildenafil)
30	Vesicoureteral Reflux	MCUG, DMSA scan	Antibiotic prophylaxis; STING/reimplant

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