In men - BPH, meatal stenosis, paraphimosis, penile constricting bands, phimosis, prostate cancer.
In women - prolapse (cystocele, rectocele, uterine), pelvic mass (gynaecological malignancy, uterine fibroid, ovarian cyst), retroverted gravid uterus.
In both - bladder calculi, bladder cancer, faecal impaction, gastrointestinal or retroperitoneal malignancy, urethral strictures, foreign bodies, stones.
Infectious and inflammatory:
In men - balanitis, prostatitis and prostatic abscess.
In women - acute vulvovaginitis, vaginal lichen planus and lichen sclerosis, vaginal pemphigus.
In both - bilharzia, cystitis, herpes simplex virus (particularly primary infection), peri-urethral abscess, varicella-zoster virus.
Drug-related:
Up to 10% AUR episodes are thought to be attributable to drugs. Those known to increase risk include:
Anticholinergics (eg, antipsychotic drugs, antidepressant agents, anticholinergic respiratory agents). Opioids and anaesthetics. Alpha-adrenoceptor agonists.
Benzodiazepines. NSAIDs Detrusor relaxants. Calcium-channel blockers Antihistamines. Alcohol.
Neurological:
More often causing chronic retention but may cause AUR:
Autonomic or peripheral nerve (eg, autonomic neuropathy, diabetes mellitus, Guillain-Barré syndrome, pernicious anaemia, poliomyelitis, radical pelvic surgery, spinal cord trauma, tabes dorsalis).
Brain (eg, cardiovascular disease (CVD), MS, neoplasm, normal pressure hydrocephalus, Parkinson's disease).
Spinal cord (eg, invertebral disc disease, meningomyelocele, MS, spina bifida occulta, spinal cord haematoma or abscess, spinal cord trauma, spinal stenosis, spinovascular disease, transverse myelitis, tumours, cauda equina).
Other:
In men - penile trauma, fracture, or laceration.
In women - postpartum complications (increased risk with instrumental delivery, prolonged labour and Caesarean section),[2]urethral sphincter dysfunction (Fowler's syndrome).
In both - pelvic trauma, iatrogenic, psychogenic.
MANAGEMENT: Foleys catheter first line. If contraindicated or failed refer to urology or try suprapubic catheterization
COMPLICATIONS: UTIs, Renal failure, Post retention diureses and hematuria 72. In CRF, main cause of Vit D deficiency is the failure of:
a. Vit D absorption in intestines b. 25 alpha hydroxylation of Vit D c. Excess Vit D loss in urine
d. 1 alpha hydroxylation of Vit D e. Availability of Vit D precursors
Ans. The key is D. 1 alpha hydroxylation of Vit D [kidney] [25 alpha hydroxilation of Vit D- liver].
VITAMIN D: FUNCTION: Absorption of calcium and phosphorus from GIT SOURCES: Oily fish, fortified food, skin synthesized VitD using sunlight Deficiency causes Rickets in children and ostomalacia in adults
Causes of Deficiency: Increased demand in pregnancy, breast feeding, Malabsorptive diseases like Crohn’s, coeliac, pancreatic insufficiency, CKD, Liver diseases
Treatment: Take vit D supplements in the form of calciferol. Tablets or injections.
Injections can be effective for upto 6 months.
All pregnant and breastfeeding women should take a daily supplement containing 10 micrograms of vitamin D
All children aged 6months to 6years should take daily vitD supplements in the form of drops
73. Pt with puffiness of face and rash showing cotton wool spots on fundoscopy. What’s the dx?
Q. 2. Why there is puffyness of face?
Q. 3. Why there is cotton wool spots on fundoscopy? What is the most common ocular manifestation of SLE?
Ans. 1. The key is SLE.
Ans. 2. Puffiness is due to lupus nephritis.
Ans. 3. SLE, can involve the retina. The classic lesion of SLE is a white fluffy appearing lesion within the retina known as a cotton wool spot. The most common ocular
manifestation in SLE is Keratoconjunctivits sicca.
SLE. Female male 5:1. More common in asians, afro caribbeans
Cause: HLA DR-2 DR-3 association, Environmental factors like UV rays, EBV and drugs (chlorpromazine, methyldopa, hydralazine, isoniazid, d-penicillamine and minocycline) Presentation: SLE is a remitting and relapsing illness
Raynaud’s phenomenon
Arthritis: Early morning stiffness, non erosive, no swelling peripheral, symmetrical Photosensivity: malar rash. Precipitated by sunlight, sparing the nasolabial fold.
Erythematous, raised & pruritic
Discoid lupus eryhtamatosus: well damarcated with scaling, on sun exposed areas Mouth ulcers
Pulmonary: pleurisy, fibrosing alveolitis
Renal: Nephritis is often asymptomatic. Glomerulonephritis is common in lupus pts Neuro: depression and anxiety are common. There may be seizures, meningitis, psychosis
Vasculitis
Criteria for diagnosis: if any 4 of these 11 are present not necessarily at the same time.
Malar rash.
Discoid lupus.
Photosensitivity.
Oral or nasopharyngeal ulcers.
Non-erosive arthritis involving two or more peripheral joints.
Pleuritis or pericarditis.
Renal involvement with persistent proteinuria or cellular casts.
Seizures or psychosis.
Haematological disorder: haemolytic anaemia or leukopenia or lymphopenia or thrombocytopenia.
Immunological disorder: anti-DNA antibody or anti-Sm or antiphospholipid antibodies.
A positive antinuclear antibody.
Investigations: FBC: Anemia, thrombocytopenia may be seen.
ESR IS RAISED BUT CRP IS USUALLY NORMAL
Antibodies: ANA: screening test but not diagnostic, 95% sensitive. Anti DNA: diagnostic and show disease activity. High specificity. Anti-Sm is the most specific antibody but 30-40% sensitive. Anti-SSA (Ro) or Anti-SSB (La) are present in 15% of patients
Anti-RNP may indicate mixed connective tissue disease with overlap SLE, scleroderma, and myositis
Anti-histone: drug-induced lupus ANA antibodies are often this type
anticardiolipin antibodies and lupus anticoagulant should be checked in lupus patients, as they are associated with APLS.
Complement C3 and C4 levels are reduced TREATMENT: Avoid sun exposure
NSAIDs for musculoskeletal pains
Steroids: Effective but can be harmful for CVS, osteoporosis. High-dose prednisolone is reserved for life-threatening SLE
Hydroxychloroquine remains first-line treatment for patients with mild SLE, especially for those with arthralgia, skin rashes, alopecia, and oral or genital ulceration
Cyclophosphamide is reserved for treatment of life-threatening disease, particularly lupus nephritis, vasculitis and cerebral disease
Mycophenolate mofetil is as effective as cyclophosphamide in inducing remission in lupus nephritis Mycophenolate mofetil is more effective than azathioprine in maintenance therapy for preventing relapse
Azathioprine is used as a steroid-sparing agent. As an alternative to cyclophosphamide, azathioprine is much safer but probably less effective
Intravenous immunoglobulins are increasingly being used in the treatment of resistant lupus and also have a role in patients who have concomitant infection and active lupus, for whom immunosuppression treatment is often
inappropriate.
Belimumab is licensed as adjunctive therapy in patients with active, autoantibody-positive SLE with a high degree of disease activity despite standard therapy
Fertility is normal and pregnancy is safe in mild or stable lupus COCP should be used with caution
74. A 35yo man presents with progressive breathlessness. He gave a hx of polyarthralgia with
painful lesions on the shin. CXR: bilateral hilar lymphadenopathy. What’s the most likely dx?
Q.2 . What is the specific name of this condition? What is the triad?
Ans. 1. The key is C. Sarcoidosis.
Ans. 2. Lofgren syndrome. The triad is i) Erythema nodosum ii) Bilateral hilar lymphadenopathy iii) Arthralgia.
Sarcoidosis:
Presentation: Lungs are in involved in more than 90% cases of sarcoidosis. There is interstitial lung disease. The painful skin lesion is erythema nodosum. Also look for Lupus pernio (chronic raised hardened, often purple lesion) may be seen on the face.
Lofgren syndrome is often a part of sarcoidosis. The triad is i) Erythema nodosum ii) Bilateral hilar lymphadenopathy iii) Arthralgia
Sarcoidosis is a multisystem disease and can involve any system/organ
Tests: ESR is often raised. Serum ACE enzyme levels are raised in 60% of times Plain CXR may show bilateral hilar or paratracheal lymphadenopathy. High resolution CT should be done. There will be restricitve pattern of disease on pulmonary function tests.
Transbronchial biopsy can demonstrate the presence of non-caseating granulomata, giving a more accurate diagnosis
Bronchioalveolar lavage may also be done
75. A child presents with clean wound, but he has never been immunized as his parents were
worried about it. There is no contraindication to immunization, what is the best management?
a. Full course of DTP b. 1 single injection DT c. 1 single injection DTP d. Only Ig
e. Antibiotic
Ans. The key is A. Full course of DTP.