Case 18: haematuria

Question 1

layers of the bladder wall

Answer 1

urothelium
lamina propria
detrusor muscle (muscularis propria)
fatty connective tissue

Question 2

properties of the urothelium

Answer 2

layer of cells that lines kidneys, ureters, bladder and some of the urethra

urine proof

can cope with being stretched as the bladder fills and then is squashed on emptying by changing shape and spreading cells out or stacking them up

Question 3

if there is invasion of the lamina propria in bladder cancer which stage is it

Answer 3

T1
non-muscle invasive bladder cancer

Question 4

if there is invasion of the detrusor muscle in bladder cancer which stage is it

Answer 4

T2
muscle invasive bladder cancer
needs radical treatment

Question 5

if there is invasion of the fatty connective tissue in bladder cancer which stage is it

Answer 5

T3
treatment of the bladder only is not likely to be curative

Question 6

which cells make up the bladder urothelium

Answer 6

transitional cells

Question 7

what is the histology of bladder cancer typically

Answer 7

transitional cell carcinoma

Question 8

less common types of bladder cancer

Answer 8

squamous cell carcinoma (usually arises from chronic inflammation such as from schistosomiasis parasites which are more common in African countries, bladder stones and long term catheters)

adenocarcinomas

Question 9

bacteria which most commonly causes UTIs

Answer 9

E coli

Question 10

how do bacteria get to the urethra

Answer 10

they are usually bacteria in the bowel lumen

these get locally transferred into the urinary tract where they multiply and cause an inflammatory host response

Question 11

why do women more commonly get UTIs

Answer 11

female urethra is much shorter

allows foe easier access of bacteria to the bladder

Question 12

how much more common is it for women to get UTIs

Answer 12

20 fold in comparison to men

Question 13

how does E.coli thrive in the urinary tract

Answer 13

have virulent mechanisms like pili and adhesins which allow for attachment to receptors on the urothelium

they produce toxins and proteases allowing them to absorb nutrients such as iron from the surrounding urothelial cells

this forms a biolfim-like bacterial community to inhibit local immune responses

Question 14

how does the body defend itself against UTIs

Answer 14

flow of urine involving full emptying of the bladder with each void

mucins in urine which aggregate bacteria to facilitate flushing them out

Tamm-horsfall protein which binds to bacteria and inhibits their attachment to urothelium

the urothelium itself is resistant to bacterial attachment and is covered with a layer of glycosaminoglycan (GAG) to further inhibit this, it also detects when a UPEC has attached to it so it can shed these urothelial cells into the urine

Question 15

how much urine should and average adult produce per hour

Answer 15

1-2ml/kg/hr

Question 16

which is oliguria

Answer 16

reduced urine output
defined as below 1mL/kg/hr in infants and less than 0.5mL/mg/hr or less than 500ml in 24hrs in children and adults

Question 17

causes of oliguria classification

Answer 17

pre-renal
renal
post-renal

Question 18

pre-renal causes of oliguria

Answer 18

dehydration
blood loss

Question 19

renal causes of oliguria

Answer 19

infections
toxins
contrast medications

Question 20

post-renal causes of oliguria

Answer 20

obstruction to the drainage of the kidneys

Question 21

what are urinary stones most commonly comprised of

Answer 21

calcium oxalate

Question 22

why do calcium stones form

Answer 22

if there is high blood serum calcium

this leads to higher amount of calcium being filtered by the kidneys into he urine

ironically people with calcium stones have less calcium in their diet

Question 23

why do oxalate stones form

Answer 23

high dietary intake which the body then excretes in urine

contained in nuts, green vegetables, chocolate, soy and potatoes

Question 24

how does calcium and oxalate bind

Answer 24

more oxalate is absorbed from the bowl if there is a problem with fatty acid uptake (particularly in the terminal ileum)

if these remain in the bowel they bind calcium, which usually binds strongly to oxalate and so both remain in the bowel to be excreted

Question 25

when are calcium phosphate stones seen

Answer 25

high blood calcium levels or abnormal urinary pH

can be due to conditions such as renal tubular acidosis (specifically distal)

Question 26

properties of calcium phosphate stones

Answer 26

very hard and so difficult to breakdown during treatment

Question 27

when do uric acid stones occur

Answer 27

when there is high levels in the urine

this is caused be high dietary intake

uric acid is in meats, oily fish, beer and surgary drinks and sweets or when cell turnover is high such as when having chemotherapy

Question 28

can uric acid stones be seen on plain X-Ray

Answer 28

if they are pure with no added calcium no they cannot be seen

Question 29

what can high uric acid in blood (hyperuricaemia cause)

Answer 29

gout

Question 30

when would you see struvite (magnesium ammonium phosphate) stones

Answer 30

recurrent UTIs

bacteria react with ammonia in urine to form elements which combine into stones

Question 31

what are staghorn stones

Answer 31

stones which fill the collecting system and look like stags horns

most commonly struvite (magnesium ammonium phosphate)