14. Haematuria and loin pain Flashcards
What is the function of the bladder
Temporary storage of urine (around 400-600mls)
assists in expulsion of urine as musculature contracts during micturition
Where does urine enter and leave the bladder (which orifices)
enters through the ureters and leaves through the urethra
Internally the bladder orifices are marked by a triangular area located within the fundus of the bladder known as what
the trigone
What are the muscles called in the bladder that contract during micturition
Detrusor muscle
name the spinsters located in the urethra
internal urethral spinster
external urethral spinster
what is the function of the internal urethral spincter in males compared to females
in males it is under autonomic control and is though the prevent seminal regurgitation during ejaculation
In females it is just a functional sphincter (ie has no muscle)
Describe the extra urethral spincter
has the same structure in both sexes and is under voluntary control
What is the difference between macroscopic haematuria and microscopic haematuria
Macroscopic/gross/frank Haematuria is visible to the eye
microscopic is no visible and only picked up in a urine dipstick
Give some reasons why your urine might be red
haemoglobin myoglobin beetroot drug: Rifampicin (antibiotic to treat tb) porphyrins
Name some causes of haematuria
bladder cancer - typically painless renal cancer UTI stones prostate disease nephrological disease no cause found
What kind of cancer presents as painless, frank haematuria.
bladder cancer
How is the main differentiating symptoms different in the following diseases;
bladder cancer
UTI
urinary tract stone
bladder cancer is painless, frank haematuria
UTI would be dysuria (pain or problem with urinating)
Renal stone would be renal colic pain
How would you investigate a 60 year old male with painless visible Haematuria and why are you doing the tests
A MSU to rule out infection
U&E to investigate renal disease
Flexible cystoscopy to rule out bladder tumour
CT urogram to exclude renal ad ureteric tumours and stone disease
PSA to rule out prostate cancer
Blood can come from any part of the renal tract; name some parts it could come from
renal (glomerular) Collecting system (papillae/calyces) ureter bladder prostate urethra consider perineal bleeding/haemospermia etc
Name some upper urinary tract causes of haematuria
renal cancer upper tract urothelial cancer renal stones UTI renal trauma intrinsic (nephrological) disease
name some lower urinary tract causes of haematuria
UTI bladder cancer Bladder stone locally advanced prostate cancer Radiation cystitis Bladder/urethral trauma Schistosomiasis
What is Schistosomiasis
also known as snail fever and bilharzia, is a disease caused by parasitic flatworms called schistosomes. The urinary tract or the intestines may be infected. Symptoms include abdominal pain, diarrhea, bloody stool, or blood in the urine
What is a renal tract ultrasound scan good for
demonstrating renal masses and whether they are solid or cysts
what is a flexible cystoscopy good for
excellent visualisation of the lower urinary tract
local anaesthetic outpatient procedure
gold standard for diagnosis of bladder cancer
Haematuria with proteinuria is more likely to be
nephrological. disorder
True or false;
Asymptomatic non-visible haematuria in young patients (less than 45) who do not smoke is very unlikely to be. due to malignancy and so patients here do not require a cystoscopy unless they have other risk factors present
true
What does urothelial cancer mean
cancer of the lining of the urinary tract, including the renal pelvis, ureters, bladder, and urethr
Patients over 45 with macroscopic. haematuria in the absence of proven UTI should be investigated in what way
Blood test for U&E, FBC and PSA (if male and over 50)
Flexible cystoscopy
and either a CT urogram or a renal ultrasound
- can get these done at GP and a one stop haematuria clinic
what is the gold standard for diagnosing bladder cancer
Flexible cystoscopy
Patients under 45 with macroscopic haematuria in the absence of infection also need what
a cystoscopy and upper tract imaging
Patients under 45 with microscopic haematuria do not need urological investigation unless then have what symptom
In this case what should they have.
loin pain
should have a non contrast CT of the urinary tract to rule out stones
As part of this they should also have their renal function. BP and urine protein excretion measured.
Bladder Cancer: tell me about the epidemiology of it
7th most. common cancer in the UK
3-4 times more common in men than women
majority of cases occur in over 60s
what are the main risk factors for bladder cancer
- increasing age
- smoking
- exposure to Carcinogens include aromatic amines, polycyclic aromatic hydrocarbons, arsenic and tetrachloroethylene (These are found in hair dyes, industrial paint, rubber, motor, leather, and rubber workers, blacksmiths etc.)
- Schistosomiasis causes squamous cell carcinoma in countries with a high prevalence
- Drinking sufficient water is thought to be protective
What is your stereotypical exam question patient who has bladder cancer present
Typical exam question is a “dye factory worker with painless haematuria”
What are the main types of bladder cancer
90% transitional cell carcinoma
10 % squamous cell carcinomas
Rarer causes are adenocarcinoma, sarcoma, small cell.
How do patients with bladder cancer usually present
visible painless haemturia
but also microscopic haematuria, irritative. urinaryy. symptoms or UTIs that don’t respond to appropriate antibiotic treatment
what percentage of bladder cancers do not affect the muscle wall of the bladder
75-80%
How are bladder cancers that do not affect the muscle wall removed
telescopic removal by transurethral resection of the bladder tumour aka TURBT
Patients with superficial invasion of the bladder wall (stage T1) or histologically aggressive disease (grade. 3) require what therapy into the bladder
BCG therapy into the bladder.
What do all patients with bladder cancer require
prolonged telescopic checking of the bladder (cystoscopy) as a follow up
Patients with cancer in ____________ cannot be cured with TURBT orBCG. and these patients are offered either a radical cystectomy or radiotherapy
the muscle wall
What does the staging of bladder cancer mean; Stage Tis Ta T1 T2 T3 T4
Tis - carcinoma in situ ie hasnt moved from where it originated
Ta- tumour confined to the epithelium
T1- tumour in submucosa connective tissue or lamina propria
T2- invades muscle
T3- extends into perivesical fat
T4- invades adjacent organs
What is the usual treatment for a Tis, Ta or T1 stage transitional cell carcinoma (TCC)
TURBT and BCG
What is the usual treatment for a T2-3 TCC
Radical cystectomy is the gold standard as radiotherapy. gives worse 5 year survival rates but preserves the bladder
What is the usual treatment for T4 TCC
Palliative chemo/radiotherapy
Chronic catheterisation and urinary diversions may help to relieve pain
What is the follow up period for high risk tumours
every 3 months for 2 years and then every 6 months
What is the follow up period for low risk tumours
first follow up in 9 months then every year
Bladder cancer grading;
what does grade 1, 2 and 3 mean
grade 1 is the least aggressive/most well differentiated histologically
grade 2 is intermediate
grade 3 is most aggressive/least well differentiated histologically
What are the symptoms and signs of renal colic due to a stone obstructing the ureter
loin to groin pain, very severe and of a colicky nature
Nausea and vomiting
occasionally LUT symptoms (frequency, urgency) is stone is in lower ureter
Haematuria (but usually non-visible so not a symptom)
Signs of tachycardia, dehydration but should not be pyrexial or have localised peritonism
What are some common differentials for renal colic
o Urological: Pyelonephritis (infection of the kidney usually caused by bacteria travelling up from the bladder)
o Gynae: ectopic pregnancy, torted ovarian cyst
o Gastro: Appendicitis, diverticvulitis
o HPB: pancreatitis, cholecystitis
o Vascular: ruptured AAA
o MICS: Musculo-skeletal pain
What is the most common type of renal stone and then name the other types
most common is calcium oxalate 65-80%- oxalate is a byproduct found in various food types
other ones are calcium phosphate 10-15%
struvite (triple phosphate) - stag horn 10-15%
Uric acid 5-10%
cystine 1%
what diagnostic tests should be carried out in someone with renal colic
bloods: FBC, U&E, calcium/CRP Urine: 85% +ve haematuria and to exclude UTI and pregnancy (bHCG) Non constrast CT scan of abdo/pelvis 70% of stones are visible on KUB x ray ultrasound may reveal hydronephrosis
Name some differentials to Haematuria and bilateral flank pain
• Renal stone disease
o Stones, obstruction, infection
• Renal tumours
o Benign tumour eg angiomyolipoma (AML)
o Malignant tumour eg renal cell carcinoma
• Infection
• Trauma (eg biopsy)
• Enlarged kidneys
o Polycystic kidney diseases (eg ADPKD)
o Obstruction (eg papillary necrosis, ureteric/bladder tumour)
• Glomerular haematuria (IgA nephropathy)
what does colic pain more likely to suggest
obstruction of the urinary. tract
what does a dull ache pain more likely to suggest
something to do with within the kidney or stretching of the renal capsule
What are NSAIDs associated with
papillary necrosis
In someone presenting with haematuria and flank pain what things to you want to ask in the history
- Pain (colic pain is more likely to be obstruction of the urinary tract. Dull ache then this suggests more likely to be within the kidney or stretching of the renal capsule)
- Fevers
- Weight loss
- Smoking
- Occupational exposure eg dyes
- Medications (aspirin, NSAIDS associated with papillary necrosis. Cyclophosphamide predisposes to malignancy)
- Past history (HTN, TB, DXT, procedures)
- Family history (ADPKD, VHL, TS)
What is a KUB x ray
a kidney, ureter and bladder x ray
Name some ways to image in someone who presents with loin pain
plain X ray (KUB) intravenous pyelogram (IVP) Ultrasound (USS) CT scan (CT urogram) MRI Angiography
What are the main causes of urological stones
50% are metabolic such as type 1 renal tubular acidosis, hyperparathyroidism, cystinuria, sarcoidosis, chrons (enteric hyperoxaluria)
urological 20%
infection 20%
immobilisation 5%
What is cystinuria
inherited disease that causes stones made of the amino acid cystine to form
what is sarcoidosis
causes granulomas to form in the organs of the body, mainly skin and lungs
What are most stones made of
75% calcium oxalate
10% struvite “staghorn”
10% Urate (radiolucent)
What is the medication management of stones
increasing fluid intake to reduce solute load
dietary modification- decrease animal protein, Na, sugar and oxalate
treat infection
alklanlinse urine
Specific medical therapy
What is the medical therapies used to treat the following
Hypercalciuria
hyperuricosuria
cystinuria
answers are
Allopurinol
Penicillamin
Bendroflumethiazide
Bendroflumethiazide (hypercalciuria)
Allopurinol (hyperuricosuria)
Penicillamine (cystinuria)
What are the main types of kidney tumours
Benign: Angiomyolipomas and oncocytoma
Malignant: Renal cell carcinomas (80%) and transitional cell carcinomas.
Tell me about transitional cell carcinoma
common and present in any part of the urinary tract
Presentation is haematuria, pain and LUTs
Commonly in over 45
o Smoking, cyclophosphamide, radiotherapy, occupational exposure, schistosomiasis infection previously
What is papillary necrosis and what are the risk factors
necrosis and shredding of the medullary papillae risk factors are; o Analgesia (acetaminophen, NSAID) o Diabetes o Sickle cell disease o Infection
need urgent drainage and antibiotic treatment is essential
What is the commonest genetic renal disease
ADPKD- autosomal dominant polycsytic kidney disease
What extra renal symptoms develop from the ADPKD
(berry aneurysms, liver, pancreas, spleen cysts, mitral valve prolapse, diverticuli)
What is the usual complications associated with ADPKD
high morbidity secondary to CVD
blood pressure control from childhood is essential
What is the management of ADPKD
family screening
monitoring renal function and kidney size
possible therapies under trial are vasopressin antagonist somastatin analogues
there is NO role for SURGERY/DECOMPRESSION
what’s bergers disease
this is IgA nephropathy where IgA lodges in your kidney
What is urine cytology and in what patients is it reserved for
it is a test that looks for abnormal cells in urine under a microscope
reserved for patients with recurrent Haematuria where initial investigations have been negative or especially high risk patients
