9 - KUB Flashcards
LUTS definition?
is a term used to describe an array of symptoms affecting the control and quality of micturition in the lower urinary tract.
Other serious causes of LUTS?
Bladder Cancer
Prostate cancer - in males
What is the aetiology of LUTS in men and women?
Most common:
Men: BPE (BPH)
Women: UTI
Drinking fluids late at night, excess alcohol intake, and excess caffeine intake can exacerbate LUTS. Polyuria caused by T2DM can mimic LUTS
Anticholingerics useful in LUTS?
Anticholinergic agents are effective in relieving overactive bladder symptoms in patients without bladder outlet obstruction. However, anticholinergic therapy has historically been contraindicated in patients with LUTS associated with BPH because of concerns for developing acute urinary retention.
https://accpjournals.onlinelibrary.wiley.com/doi/abs/10.1592/phco.28.3.356
How can LUTS be categorised?
FUN WISE
What are some important questions/examinations to do when a patient presents with LUTS?
- Associated symptoms: visible haematuria, suprapubic discomfort, or colicky pain
- DHx: anticholinergics, antihistamines, bronchodilators are known to exacerbate LUTS
- Consider DRE and examination of external genitalia
- IPSS score (International prostate symptom score)
What are some investigations done when patients present with LUTS?
Initial
- Urinalysis and culture
- Urinary frequency and volume chart (Bladder diary)
- Post-void bladder scanning and flow rate (used to establish LUTs cause)
- Bloods (FBC, U+E’s, PSA)
Specialist
- Gold standard is Cystoscopy for assessing the LUT and used if recurrent infection or haematuria
- Urodynamic studies to look at flow rate, detrusor pressure
- Upper urinary tract imaging, such as via ultrasound or CT scanning
How are people with LUTS managed conservatively and pharmacologically, apart from treating the underlying cause?
Conservatively
- Regulate fluid intake, reduce alcohol and caffeine
- Urethral milking and double voiding
- Pelvic floor exercises
- Bladder training techniques
Pharmacologically
- Alpha blockers
- 5alpha reductase inhibitors
- B3 agonists
- Anticholinergics
- Loop diuretics
What are some complications of leaving LUTS untreated?
- Risk of infection
- Renal and bladder calculi due to stagnation
- Overflow incontinence if chronic obstruction
- Renal failure
- Bilateral hydronephrosis
- Acute renal failure with BPH
How can haematuria be classified and what is the aetiology?
- Visible (VH) OR
- Non visible (a-NVH/s-NVH): symptomatic or asymptomatic OR
- Pseudohaematuria: foods like beetroot, medication (such as rifampicin or methyldopa), hyperbilirubinuria, myoglobinuria
- BPH can also cause haematuria
What questions do you need to ask in a history with someone presenting with haematuria?
- Timing:* if total suggests bladder or upper tract source, if terminal then severe bladder irritation
- Recent trauma*
- DHx*
- Smoking status* (urological cancer)
- Exposure to industrial dyes* (bladder cancer)
- Travel history* (Schistosomiasis)
Abdominal exam, possible DRE and possible genital exam
How are patients with haematuria investigated?
Initial
- Urinalysis (check for nitrates/leucocytes to indicate infection. Trace blood not haematuria, needs to be >1+)
- Baseline bloods (FBC, U+E’s, Clotting)
- PSA after counselling
- If deranged renal function take ACR
- Refer to specialists
Specialist Ix
- Flexible cystoscopy is gold standard
- Urine cytology
- US KUB imaging for NVH
- CT Urogram for VH
What is acute urinary retention and the aetiology of this?
New onset inability to pass urine which leads to pain and discomfort with significant residual volumes
Most common cause: BPH
Obstructive causes: urethral stricture, prostate cancer, constipation, UTIs
Medication: antimuscarinics, spinal anaesthesia
Neurological: severe pain, peripheral neuropathy, iatrogenic nerve damage during pelvic surgery, UMN disease (MS, Parkinson’), Bladder Sphincter Dysinergy
What are the clinical features of acute urinary retention?
- Acute suprapubic pain
- Inability to micturate
- Palpable distended bladder with tenderness
- Acute confusion in the elderly
Do PR to rule out constipation and prostate pathology
What are some investigations that are done when acute urinary retention is suspected?
- PR/PV exam
-Post-void bedside bladder scan
- Post catheterisation CSU/MSU
- Routine bloods (FBC, U+E’s, CRP)
- US KUB scan if suspect high pressure retention to look for hydronephrosis
- Monitor for post-obstructive diuresis
How is acute urinary retention managed?
- Immediate catheterisation and measure residual volume
- Treat underlying cause e.g Tamsulosin for BPH
- Check CSU for infection and review meds to see if there was a cause
- If large retention volume (>1000ml) monitor for post-obstructive diuresis
How long should a catheter be left in place after an episode of acute urinary retention and what complications would occur if they had not been treated with catheterisation?
- High-pressure urinary retention: keep in place until definitive treatment (e.g TURP) to prevent further rentions that could cause an AKI and eventually CKD
- No evidence of renal impairment: TWOC 24-48 hours after insertion. If unsuccessful try again in TWOC clinic after longer interval. If mutiple failed attempts long term catheter until definitive treatment
Complication: AKI, CKD, renal scarring, UTI, renal stones due to stasis
What is the pathophysiology of chronic urinary retention?
Most common in men: BPH
Most common in women: pelvic prolapse (such as cystocele, rectocele, or uterine prolapse)
Other: urethral strictures, prostate cancer, pelvic masses (fibroids), peripheral neuropathies, UMN diseases (MS)
How does chronic urinary retention present?
- Painless urinary retention
- Palpable distended bladder that is NOT tender
- Voiding LUTS e.g hesitancy, weak stream
- Overflow incontinence
- Nocturnal enurisis
Do DRE to check for prostate enlargement
How is chronic urinary retention investigated and managed?
Ix
- Post-void bedside bladder scan to look at retained urine
- Routine bloods (FBC, U+E’s, CRP)
- US KUB if high-pressure retention to look for hydronephrosis
Mx
- Treat underlying cause, catheterise if >1000ml residual whilst waiting for treatment
- Long term catheter/ICS with monitoring for post obstructive diuresis
- NO TWOC as concerns of repeat renal injury
What are the complications of chronic urinary retention?
- UTI
- Bladder calculi
- CKD if repeated episodes
What are the different compositions of renal tract stones (kidney and ureter stones)?
More common in males <65
- Calcium (80%): calcium oxalate (35%), calcium phosphate (10%), or mixed oxalate and phosphate (35%)
- Struvite: magnesium ammonium phosphate, cause staghorns
- Urate: only radiolucent stones
- Cystine
What is the pathophysiology of renal tract stones?
Oversaturation in the urine
Cystine: homocystinuria affects the absorption and transport of cystine in the bowel and kidneys so builds up
Urate: high levels of purine in the blood, from diet (e.g. red meats) or through haematological disorders (such as myeloproliferative disease)
Hypocitraturia: citrate is a stone inhibitor so less of it causes stoens to form
What are the clinical features of renal calculi and what are some differential diagnoses?
- Sudden onset one sided severe pain radiating from flank to pelvis (loin to groin ureteric colic) due to increased peristalsis around obstruction
- N+V
- Haematuria (usually non-visible)
- May have fever, rigors or lethargy if associated with infection (CONSIDER SEPSIS)
- Exam usually remarkable, may be some flank/renal angle tenderness but no suprapubic tenderness
DD: pyelonephritis, ruptured AAA, biliary pathology, bowel obstructon, MSK pain, lower lobe pneumonia
How are suspected renal calculi investigated?
- Urine dip and culture (microscopic haematuria)
- Routine bloods (FBC, CRP, U+Es, Urate, Ca)
- Gold standard imaging: Non-contrast CT KUB
- Other imaging: AXR with IV urogram (most stones not radiolucent and high radiation exposure) or US to assess for hydronephrosis
How are renal calculi managed initially after diagnosis on investigation before definitive management?
Initial
- IV fluid resus as lot of vomiting and reduced fluid intake
- Sufficient analgesia (opioids or PR NSAIDs)
- IV abx and urology referral if suspect sepsis
- JJ stent or Nephrostomy immediately if obstructive nephropathy causing renal damage (infection and obstruction)
How are renal calculi managed definitively if they are over 5mm so cannot be passed spontaneously with hydration and analgesia?
Extracorporeal Shock Wave Lithotripsy (ESWL): sonic waves break up then pass spontaneously. Used for small stones and radiological guidance. Contraindicated in pregnancy or a stone over a bony landmark e.g pelvis
Percutaneous nephrolithotomy (PCNL): large and staghorn calculi. Percutaneous access then nephroscope put into renal pelvis and stones fragmented by lithotripsy
Flexible uretero-renoscopy (URS): passing a scope retrograde up into the ureter, fragmented through laser lithotripsy and the fragments subsequently removed
What are some complications of recurrent kidney stones and how can we prevent stones from recurring?
- Infection
- AKI
- Renal scarring and loss of kidney function with repeated stones
What is the aetiology of bladder stones, how do they present and what issues arise if they are not treated?
- Urinary stasis from chronic urinary retention or secondary to schistosomiasis or as passed ureteric stones
- Present with LUTS
- Treated by cystoscopy allowing them to drain or lithotripsy
- Chronic irritation if left can cause SCC of the bladder
Where do kidney stones get lodged?
- VUJ
- Pelvic brim
- PUJ
What questions do you need to ask yourself when there is a renal calculi presentation?
- Composition?
- Why have they got this stone now?
- Any predisposing factors?
- Any anatomical abnormalities?
- Any family history?
- Any infection above the stone?
What is the pathophysiology of pyelonephritis?
Inflammation of the kidney parenchyma and the renal pelvis. Uncomplicated if non-immunocompromised and normal anatomy, complicated otherwise
From bacteria either ascending the lower urinary tract, from the blood stream (infective endocarditis or septicaemia) or rarely from lymphatics from retroperitoneal abscess
Neutrophils infiltrate tubules and interstitium and cause supparative inflammation (streaks of pus and renal cortical abscesses)
What organisms cause pyelonephritis?
Most common: E.Coli
Others: Klebsiella, Proteus, Enterococcus faecalis (catheters), Staphylococcus aureus (catheters), Staphylococcus saprophyticus (commensal), and Pseudomonas (catheters)
Immunocompromised: mycobacterium, yeast, fungi
What are some risk factors for developing pyelonephritis?
- Factors reducing antegrade flow of urine: e.g BPH, spinal cord injury
- Factors promoting retrograde ascent of bacteria: female short urethra, indwelling catheters and JJ stents, VUR
- Factors predisposing to infection or immunocompromise: DM, untreated HIV, corticosteroids
- Factors causing colonisation: renal calculi, menopause (less oestrogen), sexual intercourse
What are the presenting features of pyelonephritis and what are some differential diagnoses you should consider?
- Triad: fever, N+V, unliateral loin to groin pain developing over 24-48h
- LUTS: frequency, dysuria, urgency, haematuria
- Costovertebral angle tenderness with/without suprapubic tenderness (consider AAA back pain)
- DD: ruptured AAA, renal calculi, acute cholecystitis, ectopic pregnancy, PID, diverticulitis, lower lobe pneumonia
How should you manage pyelonephritis?
- A to E
- Trimethoprim or Co-amoxiclav IV abx
- IV fluids, analgesia, antiemetics
- Admit if clinically unstable, significant dehydration, or with co-morbidities such as diabetes mellitus, renal transplant graft, immunocompromised
- Consider either US or CT KUB and flexible cystoscopy for males with no risk factors/not responding to abx to check for pyonephrosis and perinephric abscess that need draining
What is chronic and emphysematous pyelonephritis?
Chronic:
- Fibrosis and destruction of the kidney due to repeated events of pyelonephritis
- More common in obstructed systems resulting in urinary reflux, such as strictures caused by UTIs, VUR
- Small, scarred shrunken kidney
- More common in children, asymptomatic, reverse any underlying cause and consider prophylactic abx
Emphysematous:
- Caused by gas forming bacteria and has high mortality
- Presents like pyelonephritis but doesn’t respond to abx
- CT imaging will show gas within and around kidney
- Most common in diabetics as high glucose converted to CO2 by enterobacteria
- If mild broad-spectrum anti-microbial cover
- If severe nephrostomy insertion or percutaneous drainage and possible nephrectomy
What is the aetiology of RCC?
- Most common: smoking
- Industrial exposure to carcinogens (cadmium, lead, aromatic hydrocarbons)
- Dialysis
- HTN
- Obesity
- Anatomical abnormalities (horseshoe, PCKD)
- Genetic disorders (BAP1, Birt-Hogg-Dube syndrome)
How does RCC present?
Triad:
- Haematuria (V or NV)
- Flank pain
- Flank mass
- Vague symptoms like weight loss
- Left sided by have left varicocele as tumour compresses testicular vein
- Polycythaemia from EPO secretion
- HTN
How is suspected RCC investigated?
- Routine bloods (FBC, U+E’s, Ca, LFTs, CRP)
- Urinalysis or non-visible haematuria and cytology
- Initially US KUB
- Gold standard: abdomen-pelvis pre and post IV contrast CT with additional chest CT for staging
- Biopsy
How is RCC managed?
Localised
- If small partial nephrectomy
- If large radical nephrectomy to remove kidney (not adrenal gland), perinephric fat, local lymph nodes
- If not suitable for surgery percutaneous radiofrequency ablation or percutaneous cryotherapy with renal artery embolisation before
- If small slow growing and little life expectancy left anyway then can just monitor
Metastatic
- Nephrectomy combined with immunotherapy (IF-a/IL2) as chemo not suitable
- Biological agents like Sunitinib/Pazopanib (Tyrosine Kinase inhibitors)
- Metastasectomy (surgical resection of solitary metastases)
What are the differences between simple and complex renal cysts?
Fluid filled sacs:
Simple: Well defined outline and homogenous features. Made from renal tubule epithelium in response to previous ischaemia
Complex: thick walls, septations, calcification, or heterogeneous enhancement on imaging. Classified with Bosniak classification and have risk of malignancy
What are some risk factors for developing renal cysts?
- Increasing age
- Smoking
- HTN
- Male
- Genetic conditions (ADPKD, tuberous sclerosis, and Von Hippel-Lindau disease)
CONSIDER RCC AS A DIFFERENTIAL
How are renal cysts investigated?
- CT or MRI imaging, with pre- and post-enhancement scans with IV contrast. Use Bosniak scoring system to stage after CT
- US picks it up incidentally
- Check U+E’s for renal function and monitor this regularly if have genetic disease that predisposes to cysts
What is the pathophysiology of the different types of urinary incontinence (involuntary leakage of urine)?
Stress
- Intra-abdominal pressure higher than urethral pressure such as coughing, straining, laughing sneezing.
- Weakness of pelvic floor seen post-partum, obesity, menopause, constipation, pelvic surgery (TURP)
Urge
- OAB (detrusor hyperactivity) leading to increased intra-vesicular pressure
- Neurogenic, infection, malignancy and cholinesterase inhibitors can all cause
Mixed
- Combination of two
Overflow
- Chronic urinary retention as stretch of bladder wall damages efferent fibres of sacral reflex and loss of bladder sensation
- BPH, spinal cord injury
Continuous
- Anatomical abnormality (such as ectopic ureter) or bladder fistulae (e.g. vesicovaginal fistula) or due to overflow
What are some investigations done when a present presents with urinary incontinence?
- MSU dipstick to check for infection and haematuria
- Post-void bladder scan
- Urodynamic assessment for UI if conservative management doesnt work
- Outflow urodynamics
- Others: cystoscopy, intravenous urogram, vaginal speculum examination, or MRI imaging
What are the different nerves and receptors involved in micturition?
Storage: Under sympathetic control by T10-L2 left and right hypogastric and S2-S4 somatic pudendal nerve under control of L centre in the pons
Voiding: Under parasympathetic control S2-S4 pelvic splanchnic
What are the conservative and surgical management options for stress urinary incontinence?
Conservative
- Lifestyle advice: less caffeine and alcohol, weight loss, smoking cessation, drinking less at end of day
- Pelvic floor muscle training for at least 3/12
- If PFMT doesn’t work offer duloxetine (serotonin-norepinephrine uptake inhibitor)
Surgical
- Tension-free vaginal tape
- Open colposuspension (involving elevation of the bladder neck and urethra through a lower abdominal incision)
- Intramural bulking agents
- Artificial urinary sphincter
What are the conservative and surgical management options for urge urinary incontinence?
Conservative
- Lifestyle advice (same as UI)
- Bladder training for minimum of 6/52
- Antimuscarinics like oxybutynin/tolterodine
Surgical
- Botulinum toxin A injections
- Percutaneous sacral nerve stimulation
- Augmentation cystoplasty
- Urinary diversion via ileal conduit.
What are the different histologies of bladder cancer and how can they be classified?
- Bladder cancer is most common urinary tract cancer. Most common in men and caught early so good prognosis
- TCC (90% of cases), SCC, Adenocarcinoma, Sarcoma
What are some of the risk factors for developing bladder cancer?
- Most important: smoking and increasing age
- Aromatic hydrocarbons (industrial dyes and rubber)
- Schistosomiasis (SCC)
- Previous radiation to pelvis
How does bladder cancer present?
- Painless haematuria (either V or NV)
- Recurrent UTIs or LUTs
- Clinical exam usually remarkable
- If metastatic may have systemic symptoms like weight loss and lethargy
What investigations are done when a bladder cancer is suspected?
- Urgent flexible cystoscopy under local anaesthetic
- Rigid cystoscopy under general if suspicious lesion found on flexible
- Biopsy on cystoscopy and consider TURBT
- CT staging to look for muscle invasive and plan TURBT
- Urine cytology (if cancer in cytology but not on cystoscopy then random biopsy on cystoscopy)
How is non-muscle-invasive bladder cancer managed?
- Carcinoma in situ or T1: TURBT
- Higher risk in situ: adjuvant intravesical therapy, such as Bacille Calmette-Guerin (BCG slowing progression) or Mitomycin C as an outpatient. Stimulates type IV hypersensitvity to activate immune cells to tumour antigens
- High risk or limited response to above: radical cystectomy
- Regular surveillance by cytology/cystoscopy of all people as high recurrence rate and if recurs more invasive
How is muscle-invasive bladder cancer managed?
- Radical cystectomy with neoadjuvant chemotherapy with cisplatin combination
- Ileal conduit formation with urostomy or bladder resconstruction from small bowel draining either urethral or catheter
- Regular follow-up with CT to monitor for local and distant recurrence. Also check B12 and folate annually due to resection ileum
How is Locally Advanced or Metastatic Bladder Cancer managed?
- Chemotherapy: either cisplatin‑based regimen or a carboplatin plus gemcitabine-based regime
- Any symptoms of the disease, such as pelvic pain, ongoing bleeding, or urinary frequency should be discussed at MDT
- Palliative options should be discussed
What is removed in a radical cystectomy?
How can you avoid renal calculi?
- Good hydration
- Thiazides
- Low protein and low salt diet
