16 The Urinary System and the Male Genital Tract Flashcards
Aims
Anatomy
Basic physiology
Introduction to the main diseases affecting the renal system and male genital tract
Overview
Urinary tract infections
Kidneys
Bladder
Prostate
Testis
Urinary Tract Infections
Very common disorder of the urinary tract
Risk factors include: Females>males Sexual intercourse Pregnancy Diabetes Urinary tract obstructions e.g. stones or catheters
Urinary Tract Infections
Bacteruria: bacteria in the urine, may be asymptomatic or symptomatic.
Urinary Tract Infection (UTI): the presence of pure growth of >10^5 organisms in fresh urine.
in urethra : Urethritis in bladder : Cystitis in prostate: Prostatitis in kidney : Pyelonephritis
E.coli is the most common causative organism (>70% of community UTIs).
Other organisms include: Staphylococcus, Proteus and Klebsiella
Urinary Tract Infections
cystitis:
frequency, dysuria, urgency, haematuria and suprapubic pain
pylonephritis:
high fever, rigors, vomiting, loin pain and tenderness
prostatitis:
flu like symptoms, few urinary symptoms and a swollen tender prostate on PR
Management
Drink plenty of fluids.
Urinate often (double voiding).
Antibiotics (trimethoprim usually first line treatment in uncomplicated UTIs).
Imaging – US in non-resolving UTIs, children, men and pyelonephritis.
Severe cases may require hospital admission specially pyelonephritis and in the elderly
Kidney Function
Maintinance of water, electrolyte and acid-base homeostasis.
Excretion of many toxic metabolic waste products (urea and creatinine).
Hormonal function
Renin – help control blood pressure
Erythropoietin- stimulates production of RBCs in the bone marrow and helps in the production of vitamin D.
Kidney Function
The functional unit is the nephron (consisting of a glomerulus and a renal tubule).
Filtration of most small molecules from the blood in the glomerulus.
Selective reabsorption in the renal tubule of most of the water and some molecules.
Maintenance of the acid-base balance.
Acute Renal Failure
A significant deterioration in renal function occurring over hours or days
There is a low urine volume (
Causes
Pre-renal
Hypoperfusion, sepsis
Renal
ATN damage to tubules due to ischaemia or nephrotoxins
Post-renal
Renal tract obstruction (eg stones, tumours)
Management
Find and treat the cause
Treat exacerbating factors ( hypovolaemia, sepsis.. etc).
Stop nephrotoxic drugs ( NSAIDs, ACE-I, gentamycin and Vancomycin)
May need renal replacement therapy (haemofiltration/dialysis)
Chronic Renal Failure
Classified into 5 stages depending on the glomerular filtration rate (GFR)
GFR is the volume of fluid filtered from the glomerular capillaries into the Bowman’s capsule per unit time
Symptoms usually occur by stage 4
Stage 1 = >90 Stage 2 = 60-89 Stage 3 = 30-59 Stage 4 = 15-29 Stage 5 =
Chronic Renal Failure Common Causes
Glomerulonephritis Diabetes Renovascular disease Hypertension Polycystic disease
Managed under nephrology team. Treat reversible causes. Avoid exacerbating factors, avoid nephrotoxic drugs.
May progress to renal replacement therapy
Glomerulonephritis
A group of disorders where there is damage to the glomerular filtration apparatus. This may cause a leak of protein or blood into the urine.
Usually there is a deposition of immune complexes in one part of the nephron
Stones
Crystal aggregates that form in the collecting ducts of the kidneys and can deposit anywhere in the renal tract.
Life time incidence 15%
Peak age 20-40 years.
Male: female = 3:1
Risk Factors
Dehydration
Dietary factors ( increase chocolates, tea and rhubarb)
Drugs ( loop diuretics, antacids, corticosteroids, theophylline and aspirin)
Renal tract abnormalities
Recurrent UTIs
Metabolic abnormalities (hyperparathyroidism, hyperthyroidism and cancer)
Stones
Patient may be asymptomatic (found accidently on x-ray or blood on dipstick ).
Pain. Kidney stones causes loin pain. Ureteric stones case renal colic (from loin to groin). Bladder and urethral stones cause pain on micturition with interrupted flow. Patients often can’t lie still from the pain.
Management
Imaging options: KUB-xray (80% of stones are visible). CT scan (99% of stones visible).
Prompt pain relief
Stones 5mm or causing obstruction may need intervention
Renal Cancer
Renal cell carcinoma
85% of all renal cancers.
Usually presents between the ages of 50 and 70 years.
2:1 male predominance .
Smoking an important risk factor along with obesity, hypertension, exposure to asbestos and certain hereditary conditions.
Presentation
50% incidental findings on abdominal imaging.
Haematuria.
Loin pain.
Abdominal mass.
Para neoplastic syndromes: e.g. polycythaemia, hypercalcaemia and hypertension.
Treatment
Radical nephrectomy +/- chemotherapy
Bladder
Cystitis is the commonest benign condition
Transitional cell carcinomas are the most common malignant condition in the bladder
Transitional Cell Carcinoma
Presentation:
Classically – painless haematuria
Frequency, urgency and dysuria can occur.
Tests:
Urine for cytology
Cystoscopy and biopsy
Treatment
Depends on stage of disease and spread
Small lesions at early stage can be managed with diathermy on cystoscopy.
Later stages – radical cystectomy or palliative chemo/radiotherapy
Prostate
Prostate is a gland that is located at the base of the bladder and around the first part of the urethra.
In normal adults weighs around 20gm.
Helps in the secretion and maintenance of semen and spermatozoa.
Benign Prostatic Hyperplasia
Common
Hyperplasia: increase in the number of cells.
BPH: increase in number of cell resulting in the formation of nodules. Prostate weighs 60-100gm
Signs and symptoms
Usually those of lower urinary tract obstruction: increased frequency, hesitancy, nocturia, terminal dribbling.
Can lead to an increased risk of infection.
Enlarged prostate on PR
If small and not symptomatic then conservative, reduce fluid intake (specially at night), reduce alcohol and caffeine, scheduled voiding.
Medical treatment: Alpha-blockers, reduces the smooth muscle tone in the prostate.
TURP (Transurethral Resection of the Prostate)
Prostate Cancer
Age
Race (more common in black people and very uncommon in Asian people)
Family history
Hormone levels
Diet – increased risk with increased fat consumption
Prostate Cancer
Signs and symptoms:
May be asymptomatic (has a slow course)
Nocturia, hesitancy, poor stream and terminal dribbling
Examination shows a hard irregular prostate
Diagnosis:
Raised PSA (prostate specific antigen) but may be normal in 30% of cases
Biopsy
Treatment
Depends on stage of disease, age of patient and comorbidities
In elderly men with many comorbidities – watchful waiting may be an option
Local disease can be treated with radical prostatectomy
Hormonal therapy and radiotherapy for more advanced cases
Testicular torsion
Sudden onset of pain in 1 testis.
Pain in abdomen, nausea and vomiting.
Testis is hot, swollen and tender.
The testis may lie high and transversely.
Most common 11-30 years old
Tests: USS with Doppler but may need exploratory surgery
Treatment: Surgery, URGENT, if still viable bilateral fixation (orchidopexy) if abnormal then orchidectomy
Testicular Tumours
Most common malignancy in males aged 15-44 years old.
Risk factors include: undescended testis, infant hernia and infertility.
Presentation: painless testicular lump often noted after trauma or infection
Germ cell tumours
Different categories
Most common is seminoma
Treatment depends on type of tumour and stage
Usually involves an orchidectomy and a combination of radiotherapy and chemotherapy
Summary
Urinary tract infections Kidneys- acute and chronic renal failure, renal stones, renal cancer Bladder-infection, TCC Prostate-BPH, prostate cancer Testis- torsion, germ cell tumours
