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Medicine Y3 TCD 13-24 > 14. Haematuria and loin pain > Flashcards

14. Haematuria and loin pain Flashcards

1
Q

What is the function of the bladder

A

Temporary storage of urine (around 400-600mls)

assists in expulsion of urine as musculature contracts during micturition

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2
Q

Where does urine enter and leave the bladder (which orifices)

A

enters through the ureters and leaves through the urethra

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3
Q

Internally the bladder orifices are marked by a triangular area located within the fundus of the bladder known as what

A

the trigone

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4
Q

What are the muscles called in the bladder that contract during micturition

A

Detrusor muscle

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5
Q

name the spinsters located in the urethra

A

internal urethral spinster

external urethral spinster

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6
Q

what is the function of the internal urethral spincter in males compared to females

A

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)

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7
Q

Describe the extra urethral spincter

A

has the same structure in both sexes and is under voluntary control

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8
Q

What is the difference between macroscopic haematuria and microscopic haematuria

A

Macroscopic/gross/frank Haematuria is visible to the eye

microscopic is no visible and only picked up in a urine dipstick

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9
Q

Give some reasons why your urine might be red

A 
haemoglobin 
myoglobin 
beetroot
drug: Rifampicin (antibiotic to treat tb)
porphyrins
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10
Q

Name some causes of haematuria

A 
bladder cancer - typically painless
renal cancer 
UTI
stones 
prostate disease 
nephrological disease 
no cause found
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11
Q

What kind of cancer presents as painless, frank haematuria.

A

bladder cancer

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12
Q

How is the main differentiating symptoms different in the following diseases;
bladder cancer
UTI
urinary tract stone

A

bladder cancer is painless, frank haematuria
UTI would be dysuria (pain or problem with urinating)
Renal stone would be renal colic pain

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13
Q

How would you investigate a 60 year old male with painless visible Haematuria and why are you doing the tests

A

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

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14
Q

Blood can come from any part of the renal tract; name some parts it could come from

A 
renal (glomerular)
Collecting system (papillae/calyces)
ureter 
bladder 
prostate 
urethra 
consider perineal bleeding/haemospermia etc
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15
Q

Name some upper urinary tract causes of haematuria

A 
renal cancer 
upper tract urothelial cancer 
renal stones 
UTI
renal trauma 
intrinsic (nephrological) disease
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16
Q

name some lower urinary tract causes of haematuria

A 
UTI
bladder cancer 
Bladder stone 
locally advanced prostate cancer 
Radiation cystitis 
Bladder/urethral trauma 
Schistosomiasis
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17
Q

What is Schistosomiasis

A

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

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18
Q

What is a renal tract ultrasound scan good for

A

demonstrating renal masses and whether they are solid or cysts

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19
Q

what is a flexible cystoscopy good for

A

excellent visualisation of the lower urinary tract
local anaesthetic outpatient procedure
gold standard for diagnosis of bladder cancer

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20
Q

Haematuria with proteinuria is more likely to be

A

nephrological. disorder

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21
Q

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

A

true

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22
Q

What does urothelial cancer mean

A

cancer of the lining of the urinary tract, including the renal pelvis, ureters, bladder, and urethr

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23
Q

Patients over 45 with macroscopic. haematuria in the absence of proven UTI should be investigated in what way

A

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
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24
Q

what is the gold standard for diagnosing bladder cancer

A

Flexible cystoscopy

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25
Q

Patients under 45 with macroscopic haematuria in the absence of infection also need what

A

a cystoscopy and upper tract imaging

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26
Q

Patients under 45 with microscopic haematuria do not need urological investigation unless then have what symptom

In this case what should they have.

A

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.

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27
Q

Bladder Cancer: tell me about the epidemiology of it

A

7th most. common cancer in the UK
3-4 times more common in men than women
majority of cases occur in over 60s

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28
Q

what are the main risk factors for bladder cancer

A
  • 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
29
Q

What is your stereotypical exam question patient who has bladder cancer present

A

Typical exam question is a “dye factory worker with painless haematuria”

30
Q

What are the main types of bladder cancer

A

90% transitional cell carcinoma
10 % squamous cell carcinomas
Rarer causes are adenocarcinoma, sarcoma, small cell.

31
Q

How do patients with bladder cancer usually present

A

visible painless haemturia
but also microscopic haematuria, irritative. urinaryy. symptoms or UTIs that don’t respond to appropriate antibiotic treatment

32
Q

what percentage of bladder cancers do not affect the muscle wall of the bladder

A

75-80%

33
Q

How are bladder cancers that do not affect the muscle wall removed

A

telescopic removal by transurethral resection of the bladder tumour aka TURBT

34
Q

Patients with superficial invasion of the bladder wall (stage T1) or histologically aggressive disease (grade. 3) require what therapy into the bladder

A

BCG therapy into the bladder.

35
Q

What do all patients with bladder cancer require

A

prolonged telescopic checking of the bladder (cystoscopy) as a follow up

36
Q

Patients with cancer in ____________ cannot be cured with TURBT orBCG. and these patients are offered either a radical cystectomy or radiotherapy

A

the muscle wall

37
Q 
What does the staging of bladder cancer mean;
Stage Tis
Ta
T1
T2 
T3 
T4
A

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

38
Q

What is the usual treatment for a Tis, Ta or T1 stage transitional cell carcinoma (TCC)

A

TURBT and BCG

39
Q

What is the usual treatment for a T2-3 TCC

A

Radical cystectomy is the gold standard as radiotherapy. gives worse 5 year survival rates but preserves the bladder

40
Q

What is the usual treatment for T4 TCC

A

Palliative chemo/radiotherapy

Chronic catheterisation and urinary diversions may help to relieve pain

41
Q

What is the follow up period for high risk tumours

A

every 3 months for 2 years and then every 6 months

42
Q

What is the follow up period for low risk tumours

A

first follow up in 9 months then every year

43
Q

Bladder cancer grading;

what does grade 1, 2 and 3 mean

A

grade 1 is the least aggressive/most well differentiated histologically
grade 2 is intermediate
grade 3 is most aggressive/least well differentiated histologically

44
Q

What are the symptoms and signs of renal colic due to a stone obstructing the ureter

A

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

45
Q

What are some common differentials for renal colic

A

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

46
Q

What is the most common type of renal stone and then name the other types

A

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%

47
Q

what diagnostic tests should be carried out in someone with renal colic

A 
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
48
Q

Name some differentials to Haematuria and bilateral flank pain

A

• 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)

49
Q

what does colic pain more likely to suggest

A

obstruction of the urinary. tract

50
Q

what does a dull ache pain more likely to suggest

A

something to do with within the kidney or stretching of the renal capsule

51
Q

What are NSAIDs associated with

A

papillary necrosis

52
Q

In someone presenting with haematuria and flank pain what things to you want to ask in the history

A
  • 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)
53
Q

What is a KUB x ray

A

a kidney, ureter and bladder x ray

54
Q

Name some ways to image in someone who presents with loin pain

A 
plain X ray (KUB)
intravenous pyelogram (IVP)
Ultrasound (USS)
CT scan (CT urogram)
MRI 
Angiography
55
Q

What are the main causes of urological stones

A

50% are metabolic such as type 1 renal tubular acidosis, hyperparathyroidism, cystinuria, sarcoidosis, chrons (enteric hyperoxaluria)
urological 20%
infection 20%
immobilisation 5%

56
Q

What is cystinuria

A

inherited disease that causes stones made of the amino acid cystine to form

57
Q

what is sarcoidosis

A

causes granulomas to form in the organs of the body, mainly skin and lungs

58
Q

What are most stones made of

A

75% calcium oxalate
10% struvite “staghorn”
10% Urate (radiolucent)

59
Q

What is the medication management of stones

A

increasing fluid intake to reduce solute load
dietary modification- decrease animal protein, Na, sugar and oxalate
treat infection
alklanlinse urine
Specific medical therapy

60
Q

What is the medical therapies used to treat the following
Hypercalciuria
hyperuricosuria
cystinuria

answers are
Allopurinol
Penicillamin
Bendroflumethiazide

A

 Bendroflumethiazide (hypercalciuria)
 Allopurinol (hyperuricosuria)
 Penicillamine (cystinuria)

61
Q

What are the main types of kidney tumours

A

Benign: Angiomyolipomas and oncocytoma
Malignant: Renal cell carcinomas (80%) and transitional cell carcinomas.

62
Q

Tell me about transitional cell carcinoma

A

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

63
Q

What is papillary necrosis and what are the risk factors

A 
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

64
Q

What is the commonest genetic renal disease

A

ADPKD- autosomal dominant polycsytic kidney disease

65
Q

What extra renal symptoms develop from the ADPKD

A

(berry aneurysms, liver, pancreas, spleen cysts, mitral valve prolapse, diverticuli)

66
Q

What is the usual complications associated with ADPKD

A

high morbidity secondary to CVD

blood pressure control from childhood is essential

67
Q

What is the management of ADPKD

A

family screening
monitoring renal function and kidney size
possible therapies under trial are vasopressin antagonist somastatin analogues
there is NO role for SURGERY/DECOMPRESSION

68
Q

what’s bergers disease

A

this is IgA nephropathy where IgA lodges in your kidney

69
Q

What is urine cytology and in what patients is it reserved for

A

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

Medicine Y3 TCD 13-24 (32 decks)

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