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Semester 3 - urinary > 28. Obstruction and urolithiasis > Flashcards

28. Obstruction and urolithiasis Flashcards

1
Q

where can urinary tract obstructions occur?

A

Can occur at any level

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2
Q

Can urinary tract obstructions be unilateral or bilateral ?

A

Can be unilateral or bilateral, complete or incomplete and of gradual or acute onset

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3
Q

What do urinary tract obstructions increase the risk of?

A

UTI, reflux and stone formation

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4
Q

What are the possible causes of urinary tract obstruction?

A
  • Calculi
  • Pregnancy
  • Benign prostatic hypertrophy (BPH)
  • Recent surgery
  • Drugs
  • Urethral strictures
  • Pelviureteric junction obstruction
  • Pelvic masses
  • Constipation
  • Inflammation – Any inflammation of the lower urinary tract will cause an obstruction
  • Tumors
  • Neurogenic disorders
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5
Q

How can pregnancy lead to urinary tract obstruction

A

High levels of progesterone relax muscle fibers in
the renal pelvis and ureters which makes people more predisposed to obstruction and fetus increases pressure on the urinary tract

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6
Q

Describe Pelviureteric junction obstruction

A
  • narrowing of renal pelvis
  • can be asymptomatic with sudden signs of retention
  • alcohol and increased fluid intake can increase risk of becoming symptomatic
  • treated with surgery
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7
Q

What may cause neurological disorders that affect urinary retention?

A

• Congenital anomalies affecting the spinal cord
• External pressure on the cord or lumber nerve
roots
• Trauma to the spinal cord

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8
Q

Describe acute urinary retention

A
  • Painful inability to void

* Residual volume 300-1500ml

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9
Q

Describe chronic urinary retention

A
  • Painless
  • May still be voiding
  • Residual volume 300-4000ml
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10
Q

What underlying problem will be present to have high residual volume in acute urinary retention?

A

Chronic urinary retention

• Acute on chronic

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11
Q

Why are UTIs more likely to occur with urinary retention

A

Stagnant pooling of urine makes infection more likely

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12
Q

How do you manage acute urinary retention?

A
  • Catheterise and record residual urinary volume
  • History
  • Examination (Abdomen, Ext. genitalia, DRE)
  • Urine Dip
  • U&Es
  • Treat any obvious cause (constipation etc.)
  • BPH – Alpha blocker, may trial without catheter (TWOC) after 1-2 weeks
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13
Q

What should be asked in history of acute urinary retention?

A

normal urine pattern?
incontinence problems?
normal streamflow?
feeling of not emptying bladder?

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14
Q

How do you manage chronic urinary retention?

A
  • Catheterise and record residual volume
  • History
  • Exam
  • Urine dip, U&Es
  • Plan for long-term catheterisation or intermittent self catheterisation. Would not attempt TWOC.
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15
Q

What are the two types of chronic urinary retention and compare?

A 
--->High pressure
• Abnormal U&Es, hydronephrosis
• Repeat episodes can cause permeant renal scaring and CKD
---> Low pressure
• Normal renal function
• No hydronephrosis
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16
Q

What will you normally find in history of chronic urinary retention?

A

can void but feeling of not emptying bladder

poor urinary flow

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17
Q

What is post obstructive diuresis and what causes it?

A
  • Following resolution of urinary retention through catheterization
  • Kidneys can often over-diurese
  • due to losing water to expel all the built up solute and back up of fluid caused loss of countercurrent resulting in more water loss
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18
Q

How can post obstructive diuresis affect AKI?

A

• Can lead to worsening AKI

19
Q

How is post obstructive diures managed?

A
  • Urine output should be monitored for 24hours post catheterization
  • Patients with high urine volumes should be supported with IV fluids
20
Q

What is hydronephrosis?

A

Dilation of the renal pelvis and calyces due to obstruction at any point in the urinary tract causing increased pressure and blockage

21
Q

What is the effect of sever hydronephrosis?

A

• Progressive atrophy of the kidney develops the back
pressure from the obstruction is transmitted to the distal parts of the nephron and glomerulus.
• GFR declines and, if the obstruction is bilateral the patient goes into renal failure.

22
Q

What leads to unilateral or bilateral hydronephrosis?

A
  • Unilateral – caused by an upper urinary tract obstruction

* Bilateral – caused by obstruction in the lower urinary tract

23
Q

What will obstruction at pelviureteric junction result in?

A

hydronephrosis

24
Q

What will Obstruction at the ureter result in?

A

hydroureter, eventually developing hydronephrosis

25
Q

What will Obstruction of the bladder

neck/urethra result in?

A

bladder distension with hypertrophy, eventually leading to hydroureter and thus hydronephrosis

26
Q

What are symptoms of acute ureteric obstruction?

A
  • renal colic - pain from loin to groin
  • clammy
  • sweating
  • nausea
  • vomiting
27
Q

what are the causes of acute ureteric obstruction?

A

Usually caused by calculus, but can be due to

blood clots or sloughed papilla

28
Q

Are ureteric obstructions unilateral or bilateral and when does it lead to acute renal failure?

A
  • Usually (not always) a unilateral problem
  • Leads to acute renal failure if bilateral
  • Presents as anuria or oliguria
29
Q

What can develop as a result of ureteric obstruction ?

A

Pyonephrosis can develop

30
Q

What is Pyonephrosis?

A

An infected, obstructed kidney

31
Q

What is the severity of Pyonephrosis?

A
  • Urological emergency

* Failure to promptly decompress may lead to death from sepsis and permeant loss of renal function

32
Q

How is pyonephrosis treated?

A

decompress kidney and treat infection e.g. antibiotics

33
Q

How can upper urinary tract obstructions be diagnosed?

A
  • Diagnosis with CT or USS –show structure not function

* Diuretic Renography (MAG3) is a functional test of kidney

34
Q

What are two drainage methods of upper urinary tract?

A

• Nephrostomy • JJ Stent

35
Q

Define urolithiasis.

A

kidney stones

36
Q

What is the incidence and recurrence rate of urinary tract calculi?

A

• Affects 10% of the population. Far more common
in men and Caucasians.
• Dehydration increases the concentration of the urine and is a predisposing factor. High recurrence rate 60-80%

37
Q

What are the 3 common sites of urinary calculi?

A
  • Pelviureteric junction
  • Pelvic brim
  • Vesicoureteric junction
38
Q

What is used to diagnose kidney stones?

A 
CT KUB (CT of the kidneys, ureters and bladder)
- allows identification of stone size and position
39
Q

What are the 5 types of calculi?

A
  • Calcium oxalate stones – most common. Associated with hypercalcemia and primary hyperparathyroidism and hyperoxaluria.
  • Mixed calcium phosphate and calcium oxalate stones – associated with alkaline urine
  • Magnesium ammonium phosphate stones –associated with urea splitting bacteria
  • Uric acid stones – associated with gout and myeloproliferative disorders
  • Cystine stones – patients with inherited cystinuria
40
Q

What is the classical presentation of urolithiasis?

A

• Renal stones may cause a continuous dull ache in the loins
• Ureteric stones cause classical renal colic due to the increase in peristalsis in the ureters in response to the passage of a small stone. Typically radiates from loin
to groin. Patient appears sweaty, pale and restless with nausea and vomiting
• Bladder stones cause strangury: the urge to pass something that will not pass
• Recurrent and untreatable UTIs, hematuria or renal failure
• They may be asymptomatic

41
Q

How is urolithiasis treated?

A
  • Management involves adequate analgesia and a high fluid intake.
  • Urine should be sieved for analysis.
  • Extracorporeal shock wave lithotripsy (ESWL)
  • Ureteroscopic destruction or removal of stones
  • Percutaneous nephrolithotomy (PCNL) : endoscopic removal of the stone
  • Open surgical removal
42
Q

Describe ESWl

A

shock waves are used to fragment the calculi into small pieces which will then pass out in the urine

43
Q

how can further stone formation be prevented?

A

a high fluid intake and correction of any underlying metabolic abnormality

44
Q

What sized stones may pass through urine?

A
  • Stones of 4-5mm or less usually pass spontaneously

* Larger stones might require surgical intervention.

Semester 3 - urinary (33 decks)

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