Benign Urological Disease Flashcards
what is haematuria?
presence of blood in urine
what is the difference between visible and non-visible haematuria?
- Visible haematuria: the patient has seen blood
- Non visible which can be classified as symptomatic when in association with urological symptoms such as frequency or dysuria or asymptomatic (insurance medical)
what investigations are useful in a patient with haematuria?
Urine culture urine cytology flexible cystoscopy renal ultrasonography Patients may have CT, MRI or renography
how common is cancer in patients with haematuria?
5-10% with NVH have urological cancer
20-25% with VH have urological cancer
what is the management for patients with negative haematuria investigations?
eGFR to identify CKD
VH and negative urological investigations or eGFR <60ml/min/1.73m2 should be refered to nephrologist
NVH – eGFR <60ml/min/1.73m2 refer to nephrologist
Proteinuria – P:Cr >45mg/mmol – refer nephrologist / no proteinuria – treat as CKD stage 1 and 2
name classic prostatic symptoms?
hesitancy poor flow frequency urgency nocturia terminal dribbling Little relationship between these symptoms and prostate size urinary flow residual urine volume Age matched men and women have similar ‘prostate’ symptom scores
how can baseline lower urinary tract symptoms be measured?
using a symptom index- international prostate symptom score (IPSS)
lower urinary tract symptoms can rarely be caused by what?
neurological disease causing spinal cord or cauda equina compression, or due to pelvic or sacral tumours associated symptoms including back pain, sciatica, ejaculatory disturbances, sensory distrubances in legs, feet and perineum. Confirm with MRI scan
what can cause lower urinary tract symptoms?
pathology in prostate, bladder, urethra, other pelvic organs or neurological disease affecting nerves innervating bladder. The context in which they occur can indicate cause
what does lower urinary tract symptoms with heamaturia suggest?
bladder cancer
what is recent onset bedwetting in elderly men usually due to?
high pressure chronic retention. Diagnosis is confirmed by palpating enlarged, tense bladder and by drainage of a large volume (>2L) of urine following catheterisation
what factors are taken into consideration on the international prostate symptom score sheet?
incomplete emptying frequency intermittency urgency weak stream straining nocturia
what is loin (flank) pain assumed to be?
Presumed to be urological in origin on basis that kidneys are located in the loins however other organs are located here so pathology within which can be the source of pain and pain from extra-abdominal organs can radiate to loins
what does acute loin pain suggest?
obstruction of ureter such as stone
what does chronic loin pain suggest?
disease within kidney or renal pelvis
what is the commonest cause of sudden onset severe flank pain?
passage of a stone formed in the kidney down the ureter
describe ureteric stone pain?
characteristically starts suddenly (within minutes), is colicky in nature and radiates to groin as stone passes into lower ureter
The location of pain doesn’t give a good indication of position of the stone, except when patient has pain or discomfort in penis and a strong desire to void, suggesting that the stone has moved into intramural part of the ureter
The patient cannot get comfortable-they often roll around in agony.
of the patients presenting with ureteric stone pain how many don’t have a stone confirmed on imaging?
50%
in what groups of people is acute loin pain less likely to be due to a ureteric stone?
women
extremes of ages
what are the non stone urological causes of acute loin pain?
clot or tumour
pelviureteric junction obstruction
infection
describe the clinical features of urological clot or tumour?
loin pain and haematuria are often assumed to be due to a stone, but it is important to approach the investigation of such patients from perspective of haematuria
describe the clinical features of pelviureteric junction obstruction?
may present acutely with flank pain severe enough to mimic a ureteric stone. A CT will demonstrate hydronephrosis with normal caliber ureter below PUJ and no stone. Renography is used to assess functional obstruction
describe the clinical features of urological infection?
eg acute pyelonephritis, these patients have high fever, whereas ureteric stone patients don’t and are often systemically very unwell
what are the vascular causes of acute loin pain?
leaking abdominal aortic aneurysm
what are the medical causes of acute loin pain?
pneumonia
MI
malaria
what are the gynaecological and obstetric causes of acute loin pain?
ovarian pathology eg tristed ovarian cyst
ectopic pregnancy
what are the GI causes of acute loin pain?
Acute appendicitis
IBD
Diverticulitis
Intestinal obstruction
what are the other causes of acute loin pain?
testicular torsion
spinal cord disease (prolapsed intervertebral disc)
what are the urological causes of chronic loin pain?
-Renal cell carcinoma
-Transitional cell carcinoma of renal pelvis or ureter
-Renal stones
-Renal infection
-PUJO
Ureteric pathology (Ureteric reflux, Ureteric stone)
what are the non-urological cause of chronic loin pain?
GI (Bowel neoplasms, Liver disease) Spinal disease (Prolapsed intervertebral disc, Spinal metastases)
how can you distinguish between urological vs non urological loin pain?
- History and examination-patients with ureteric colic often move around bed in agonist, patients with peritonitis lie still
- Palpate abdomen for signs of peritonitis (abdominal tenderness or guarding)
- Examine for abdominal masses (pulsatile and expansile=leaking abdominal aortic aneurysm
- Examine back, chest and testicles
- Pregnancy test in women
what is urinary incontinence?
the complaint of any involuntary leakage of urine
what is stress urinary incontinence?
the complaint of involuntary leakage of urine on effort, exertion, sneezing or coughing
what is urge urinary incontinence?
the complaint of any involuntary leakage of urine accompanied by or immediately preceded by urgency
what is mixed urinary invontinence?
a combination of SUI and uui
describe the prevelance of urinary incontinence in women?
25% of women >20 have UI of whom 50% have SUI, 10-20% pure UUI and 30-40% MUI
describe the features of SUI?
Result of bladder neck/urethral hypermobility and/or neuromuscular defects causing intrinsic sphincter deficiency (sphincter weakness incontinence). As a consequence, urine leaks whenever urethral resistance is exceeded by an increase in abdominal pressure occurring eg during exercise or coughing
describe the features of UUI?
May be due to bladder overactivity or less commonly due to pathology that irritates the bladder (infection, tumour, stone). Symptoms resulting from involuntary detrusor contractions may be difficult to distinguish from those due to sphincter weakness. In some patients detrusor contraction can be provoked by coughing, thus distinguishing leakage due to sui from that due to bladder overactivity canbe difficult
describe the features of constant leak?
Suggest fistulous communication between bladder and vagina (due to surgical injury at the time of hysterectory or caeserian section) or rarely, the presence of ectopic ureter draining into vagina (urine leak is usually low in volume but lifelong
describe the role of examination in patients with urological disease?
Because of retroperitoneal (kidney, ureters) or pelvic location(bladder and prostate), urological organs are relatively inaccessible to the examining hand when compared with spleen, liver or bowel. For the same reason, for the kidneys and bladder to be palpable implies fairly advanced disease state
describe the characteristics of an enlarged bladder?
Arises out of the pelvis, dull to percussion, pressure of examining hand may cause a desire to void
what are the causes and characteristics of abdominal distension?
- Foetus – smooth firm mass, dull to percussion, arising out of the pelvis
- Flatus – hyper-resonant (may be visible peristalsis if intestinal obstruction)
- Faeces – palpable in the flanks and across the epigastrium, firm and may be indentable, may be separate masses in the line of the colon
- Fat –
- Fluid (ascites) – fluid thrill, shifting dullness
what are the characteristics of enlarged kidneys?
The mass lies in a paracolic gutter, moves with respiration, dull to percussion and can be felt bimanually. It can also be balloted (bounced like a ball) between your hands – one placed on the anterior abdominal wall and one on the posterior
what are the causes of an enlarged kidney?
renal carcinoma, hydronephrosis, pyonephrosis, perinephric abscess, polycystic disease
what are the characteristics of an enlarged liver?
Mass descends from under the right costal margin, you cannot get above it, it moves with respiration, dull to percussion and has a sharp or rounded edge. Surface may be smooth or irregular
what are the causes of an enlarged liver?
infection, congestion (heart failure, hepatic vein obstruction) cellular infiltration (amyloid), space occupying lesions (primary hepatic cancer, metastases, hydatid cyst,abscess) cirrhosis
what are the characteristics of an enlarged spleen?
Mass appears from underneath the left costal margin and enlarges towards the right iliac fossa, is firm, smooth and may have a palpable notch. You cannot get above it, it moves with respiration, dull to percussion, cannot be felt bimanually
what are the causes of an enlarged spleen?
infection (bacterial, viral, protozoal and spirochaete), cellular proliferation, congestion, cellular infiltration, space occupying lesions
what is nephrolithiasis?
renal stones
what are the causes of renal stones?
- elevated levels of urinary solutes (calcium, uric acid, osylate, sodium)
- decreased levels of stone inhibitors (citrate and magnesium)
- low urinary volume
- low or high urinary pH
- these lead to urine supersaturation
- UTI
what are the investigations for patients with suspected renal stones?
urinalysis FBC serum electrolytes, urea and creatinine urine pregnancy test non contrast helical CT scan stone analysis
describe the process of micturition?
- micturition is voluntary act by CNS
- coordinated by pontine micruition centre
- urine storage requires contraction of internal and external urethral sphincters and relaxation of the bladder
- somatic nerves mediate external urethral sphincter contraction, and sympathetic nerves trigger internal urethral sphincter contraction
- pudendal nerve stimulates external urethral sphincter
- involuntary and voluntary input to structures such as lateral vaginal walls (levator ani muscle, fascia, ligamentous attachments) can result in increase outlet resistance
- submucosal vascular plexus contributes to maintaining urethral turgor and sustaining closure of urethral sphincter
describe voiding?
-requires coordinated urethral sphincter relaxation of bladder contraction
-initiation under parasympathetic nervous system and triggered by signals originating from S2-S4 and travel through hypogastric nerves. when these are stimulated these releace acetylcholine which binds to muscarinic receptors in the bladder.
contraction of smooth muscle of bladder, detrusor muscle, occurs resulting in urinary flow through relaxed urethra
describe the inhibition of voiding?
controlled by pontine storage centre receiving afferent signals from distended bladders. this mediated sympathetic nervous system to release adrenaline binding to beta receptors on bladder wall and alpha receptors on bladder neck and urethra which triggers smooth muscle relaxation inhibiting detrusor contraction. stimulation at alpha receptors causes muscle contraction both these inhibit micturition.
both ANS contain afferent input to recognise bladder fullness (a delta and c fibres)
describe the pathophysiology of urge incontinence?
disruption to well coordinated process of micturition
either neurogenic or myogenic origin
describe pathophysiology of stress urinary incontinence?
caused by anatomical abnormality such as cystocoele or urethral hypermobility. urethral closure pressure no longer maintained or no longer exceeds intra abdominal pressure creasing a pressure gradient leading to loss off urine involuntarily
support structures may be intact but urethra may be weak=intrinsic sphincter deficiency
