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Urinary > 9.2 Urinary Tract Disruption > Flashcards

9.2 Urinary Tract Disruption Flashcards

1
Q

Where do urinary tract obstructions occur?

A

At any level between the kidney to the urethra

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2
Q

During bilateral urinary obstruction where is the obstruction likely to be?

A

At the bladder or at the urethra as ureters have converged

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3
Q

What are urinary tract obstructions a risk factor for?

A

UTI - stagnant pools of urine
Urine reflux - up ureter
Stone formation

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4
Q

What are common causes of urinary tract obstruction?

A 
Tumours (kidney, cervix, bladder)
Strictures at pelvis ureteric junction
Stag horn calculus / ureteric calculus 
Pregnancy - obstruction of ureter 
Blood clot
Endometriosis
Damage to nerves involved in micturition
Prostatic enlargement 
Urethral stricture
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5
Q

What are calculi?

A

Renal stones

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6
Q

What are causes of urinary retention?

A 
Calculi
Pregnancy 
Benign prostatic hypertrophy - occlusion of prostatic urethra
Recent surgery
Drugs
Urethral strictures
Pelviureteric junction obstruction - congenital abnormality 
Pelvic masses
Constipation
Inflammation of lower urinary tract/UTI
Tumours
Neurogenic disorders
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7
Q

How is urinary retention imaged on a CT?

A

Enlarged bladder

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8
Q

How does pregnancy cause urinary retention?

A

progesterone relaxes muscle fibres in the renal pelvis and ureters causing dysfunctional obstruction. Pressure of growing foetus can cause occlusion

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9
Q

What drugs can cause urinary retention?

A

opioids, anticholinergics - decrease contraction of detrusor

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10
Q

What neurogenic disorders can cause urinary retention?

A

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

Affect micturition pathways

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11
Q

What is acute urinary retention?

A

Sudden inability to void
Painful
Residual volume of 300-1500ml
Can see enlarged / distended bladder

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12
Q

What is chronic urinary retention?

A

Long term urinary retention
Painless
May still be voiding but have large residual volume (300-4000ml)

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13
Q

What can cause acute urinary retention?

A

Flare up of begging prostatic hypertrophy
Urethral stricture
Tumours

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14
Q

What can cause chronic urine retention?

A

Gradual occlusion

Neurological disorders.

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15
Q

What is acute on chronic urinary retention?

A

Chronic retention, with a sudden acute urinary retention episode. Can be caused by the chronic urinary retention (e.g. stones formed due to pooling of urine) or not related.

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16
Q

What is the treatment of acute urinary retention?

A

Catheterise and record residual urinary volume
History (urine stream, urine volume, frequency, continence, vesicle tenesmus)
Examination (abdomen, external genitalia, digital rectal examination)
Urine dip (UTI)
U&E
Treat any obvious cause (constipation)
BPH - alpha blocker, TWOC after 1-2 weeks

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17
Q

What can acute urinary retention result in if not treated?

A

Hydronephrosis -> renal damage -> renal failure

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18
Q

How would we manage chronic urinary retention?

A

Catheterise and record residual volume
History of urinary complications and symptoms
Examination (often have vesicle tenesmus, poor uric stream or flow)
Urine dips
U&E
Determine if High pressure urinary retention or low pressure urinary retention
Plan for long-term catheterisation or intermittent self catheterisation. Would not attempt TWOC

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19
Q

How does high pressure chronic urinary retention present?

A

High pressure build up of urine in the bladder.
Hydronephrosis as urine back up ureters and kidney. Can develop to have deranged U&Es and AKI (post renal cause). Unable to clear K+ from body, hyperkalaemia. Over time can cause permanent renal scarring and CKD

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20
Q

How does low pressure urinary retention present?

A

Bladder compliant but not emptying. Normal renal function, no hydronephrosis.
Likely to be due to neurological damage.
Long term catheterisation (suprapubic catheter/ intermittent self catheterisation)

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21
Q

Why must urine output be monitored for 24hours post catheterisation for treating urinary obstruction?

A

As can develop post-obstructive diuresis following hydronephrosis as suddenly excreting build up of waste products. Do not want patient to become hypovolaemic.
Can lead to worsening AKI

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22
Q

What is post- obstructive diuresis?

A

Over-diuresis by the kidneys following catheterisation to treat obstructive urinary retention. Occurs to clear the waste solutes in the blood the kidneys couldn’t previously expel. Can lead to worsening AKI.

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23
Q

How do we support patients with post-obstructive diuresis?

A

IV fluid

24
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.

25
Q

What causes a unilateral hydronephrosis?

A

Upper urinary tract obstruction (ureter or kidney)

26
Q

What causes a bilateral hydronephrosis?

A

Lower urinary tract obstruction (BPH in males)

27
Q

How does hydronephrosis appear on a CT scan?

A

Dilated renal pelvis

28
Q

How is the kidney affected in long term hydronephrosis?

A

Progressive atrophy of the kidney. Transmitted through the nephron.
GFR declines
If bilateral the patient can go into renal failure

29
Q

What occurs if there is an obstruction at the pelviureteric junction?

A

Hydronephrosis

30
Q

What occurs if there is an obstruction at the ureter?

A

hydroureter, eventually developing hydronephrosis

31
Q

What occurs if there is obstruction at the bladder neck/urethra?

A

bladder distension with hypertrophy of bladder wall and diverticula, eventually leading to bilateral hydroureter and thus hydronephrosis

32
Q

What is acute ureteric obstruction?

A

Obstruction within the ureter.
Patients present with renal colic, clammy, sweaty, nausea, vomiting.
Usually unilateral, if bilateral can lead to renal failure.
Bilateral patients have anuria/oliguria

33
Q

What is renal colic?

A

Sharp pain from the lower back (loin) that radiates to the groin

34
Q

What causes acute ureteric obstruction?

A

Often caused by a renal calculus getting stuck in the ureter, pain as ureter contracts to try and push calculus through
Can also be caused by blood clots or a slough papilla.

35
Q

What are slough papilla?

A

A slough papilla occurs due to renal papilla necrosis often caused by ischaemia, resulting in the papilla sloughing into the lumen

36
Q

What can develop as a complication of acute ureteric obstruction?

A

Pronephrosis - infection of the kidneys collecting system. Pus collects in the renal pelvis causing distension of the kidney

37
Q

What is pronephrosis?

A

Urological emergency. An infected, obstructed kidney. Failure to decompress promptly can lead to death from sepsis and permanent loss of renal function

38
Q

How do we diagnose a urinary tract obstruction?

A 
CT scan or ultrasound - would show hydronephrosis, stones appear brightly on CT
Diuretic renography (MAG3)
39
Q

What is a diuretic renography?

A

A functional test that tells us what’s happening in the kidney. Patients given radiotracer and we monitor radioactivity of the urine. Patients also given frusamide after

40
Q

How do we drain the upper urinary tract?

A

Nephrostomy

JJ stent

41
Q

What is a urolithiasis?

A

A urinary calculi

42
Q

Who does urolithiasis most commonly affect?

A

Men
Caucasians
Dehydrated

43
Q

Where are the most common sites for urolithiasis?

A
  • Pelviureteric junction
  • pelvic brim
  • vesicoureteric junction
    But can form anywhere in the urinary tract
44
Q

How do we diagnose urolithiasis?

A

CT scan of kidneys, ureters and bladder as show up very clearly due to high calcium content

45
Q

What are the 5 types of calculi?

A
  1. Calcium oxalate stones
  2. Mixed calcium phosphate and calcium oxalate stones
  3. Magnesium ammonium phosphate stones
  4. Uric acid stones
  5. Cystine stones
46
Q

What is the most common calculi?

A

Calcium oxalate stones

47
Q

What are calcium oxalate stones associated with?

A

Hypercalcaemia
Primary Hyperparathyroidism
Hyperoxaluria

48
Q

What are mixed calcium phosphate and calcium oxalate stones associated with?

A

Alkaline urine

49
Q

Why does the presentation of urolithiasis vary?

A

As site of stone can present differently. Can be asymptomatic

50
Q

How does a renal stone present?

A

Continuous dull ache in loins

51
Q

How do ureteric stones present?

A

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

52
Q

How do bladder stones present?

A

Strangury (the urge to pass something that will not pass)

53
Q

What symptoms can indicate urolithiasis?

A

Recurrent untreatable UTIs
Hematuria
Renal failure

54
Q

Which calculi do not appear on an X-ray?

A

Uric acid stones

55
Q

What is the general management for urolithiasis?

A

Adequate analgesia
High fluid intake
Urine sieved for analysis - then correct any underlying metabolic abnormality

56
Q

What size stones can pass easily in urine?

A

<5mm

57
Q

What surgical interventions can be used to treat urolithiasis?

A
  • Extracorporeal shock wave lithotripsy (ESWL): shock waves are used to fragment the calculi into small pieces which will then pass out in the urine
  • Ureteroscopic destruction or removal of stones
  • Percutaneous nephrolithotomy (PCNL) : endoscopic removal of the stone
  • Open surgical removal

Urinary (18 decks)

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