Acute urinary problems

Question 1

What two things are measured in AKI and help to define AKI? What is the main clinical clue?

Answer 1

Serum urea and creatinine

REDUCED URINE OUTPUT is the main clinical clue - consider AKI in anyone with reduced urine output

Question 2

How is AKI staged and what are the stages?

Answer 2

KDIGO staging

1. Creatinine increased by >26umol or 1.5X baseline PLUS urine output <0.5mL/kg/h for 6 consecutive hours
2. Creatinine increase by 2-2.9X baseline PLUS urine output <0.5mL/kg/h for 12 consecutive hours
3. Creatinine increase >3X baseline PLUS urine output of <0.3L/kg/hr for >24h or anuria for 24h

Question 3

How is it most useful to split up the major causes of AKI?

Answer 3

Into pre-renal, intra-renal or post-renal causes

Question 4

What are the most common pre-renal causes of AKI?

Answer 4

Nearly always due to HYPOPERFUSION of the kidney (these are very common reasons for AKI to develop)

• Hypovolaemia
• Sepsis
• Renal artery stenosis

Question 5

What are some common intra-renal causes of AKI?

Answer 5

Acute tubular necrosis - often as result of pre-renal damage or nephrotoxic drug (e.g. contrast medium, NSAIDs)
Glomerular damage (common in autoimmune disease e.g. SLE or HSP)
Interstitial damage (Due to drugs, infiltration, lymphoma)
Vascular (vasculitis, malignant hypertension, thrombus(

Question 6

What are some common post-renal causes of AKI?

Answer 6

Renal stones, luminal malignancies or extrinsic compression (e.g. from tumour or retroperitoneal fibrosis)

Question 7

What are some risk factors for developing AKI?

Answer 7

Age >75, CKD, Cardiac failure, peripheral vascular disease, Diabetes, chronic liver disease, drugs (always look for newly started medications), sepsis, poor fluid intake

Question 8

How should you investigate someone if you suspect they’ve got an AKI?

Answer 8

Do a bedside investigation looking for rashes, fevers or any examples of the patient being systemically unwell
LOOK FOR: palpable bladder (?retention), palpable kidneys or renal bruits
URINE DIP
BLOODS; FBC, U&E (look for K+), LFT, CRP, Clotting, CK, ABG
IMAGING: Renal USS and bladder scan

Question 9

How should you initially manage a patient with AKI?

Answer 9

Assess volume status and give them fluids if necessary (0.9% NaCl good - avoid any fluids with potassium)
STOP NEPHROTOXIC DRUGS
Search for and treat underlying cause and refer to nephrology if necessary

Question 10

What common drugs are nephrotoxic?

Answer 10

ACE-inhibitors 
Diuretics 
Intravenous contrast 
Antibiotics - gentamicin and nitrofurantoin 
Metformin 
Opioids 
NSAIDs
Decrease BP (B-blockers)
Lithium 

A DIAMOND + Li

Question 11

In an elderly patient that comes in confused, what two urinary problems should you always consider?

Answer 11

UTI

ACUTE URINARY RETENTION

Question 12

In a patient who is in acute urinary retention what can you expect to find on examination?

Answer 12

An enlarged, tender bladder that is dull to percussion

Question 13

Who is acute urinary retention more common in and why?

Answer 13

MEN
Due to prostatic hypertrophy
Also common post-operatively and due to urethral stricture

Question 14

What are some common causes of acute urinary retention in women?

Answer 14

Retroverted gravid uterus
Atrophic urethritis
MS (multiple sclerosis)

Question 15

What are some relevant investigations in urinary retention?

Answer 15

ALWAYS SUSPECT SPINAL PATHOLOGY
Perform peripheral nerve assessment of the lower limb, also perform a PR and assess anal tone
When performing a PR in men also take the opportunity to assess the prostate

Question 16

How should acute urinary retention be managed?

Answer 16

Urgent bladder decompression as long as there is no contraindication
Urethral catheterisation or consider supra-pubic if urethral not possible
Once urine has been passed then DIP IT for infection and treat that

Question 17

How will renal colic present?

Answer 17

Intermittent flank or loin pain that might also travel down to the groin
SEVERE PAIN that comes and goes in waves - this pattern of pain is due to ureteric peristalsis
Might also have urinary symptoms of:
- Anuria, dysuria, increased frequency, urgency, suprapubic tenderness, changes in smell or colour of urine, haematuria, sweating, fever, N&V

Question 18

What is a common cause of renal colic?

Answer 18

KIDNEY STONES (Sweaty, N&V, and excruciating pain will predominate)

Question 19

How should you investigate someone with renal colic pain?

Answer 19

KUB USS
Urine dip - blood leucocytes 
Pregnancy test in women
CT
Bloods: FBC, U&E, WCC, CRP

Question 20

How should someone with renal colic be managed initially?

Answer 20

Painkillers (might need IV)
FLUIDS - really important to keep patient hydrated.
Shock therapy can break down stones to make them easier to pass

Question 21

How will testicular torsion present?

What will appear like on examination?

Answer 21

Sudden onset SEVERE PAIN in the testicles, upper thigh, groin or lower abdomen
Vomiting
O/E: Red, Swollen, tender testis, ABSENCE of cremasteric reflex, might lie more horizontally than vertically

Question 22

Who is testicular torsion most common in?

Answer 22

Boys in neonatal period and then again between the ages of 11-30 (peak during puberty)

Question 23

How should this be investigated?

Answer 23

It shouldn’t. If you suspect torsion you need to contact uro-surgery immediately because it is time sensitive

Question 24

How do we define a UTI?

Answer 24

Sometimes by the symptoms but sometimes there are none (ASYMPTOMATIC BACTERURIA) bactria >10^5 in urine
- Sometimes asx bacteriuria need treating and sometimes not (PREGNANT WOMEN NEED TREATMENT)

Question 25

What are some symptoms of UTI?

Answer 25

Urgency, Frequency, Changes in colour or smell to urine, dysuria, supra-pubic tenderness, blood in urine, sweating, fever, N&V

Question 26

What sort of symptoms would make you concerned that the LUTI had become an UUTI?

Answer 26

Fever, rigors, sweating, malaise, anorexia, loin/back pain and vomiting
MORE SYSTEMIC SYMPTOMS OF UNWELL

Question 27

What is the most common cause of UTI?

Answer 27

Gram negative bacteria from the gut (usually E.coli) but should always do a culture to make sure you’re treating to right bug

Question 28

How do we investigate a UTI

Answer 28

Urine dip (look for nitrites - sensitive, leucocytes, protein, blood)
Urine microscopy and culture

Question 29

Initial management of UTI

Answer 29

If Uncomplicated: 3-6 day course of trimethoprim or nitrofurantoin and advice about hydration

Asx Bacteriuria in pregnant women give amoxicillin

MEN should be given 2 weeks of ciprofloxacin, trimethoprim or co-amoxiclav and followed up

IF CATHETER only treat if symptomatic - 7 days of ciprofloxacin or co-amoxiclav