Conditions of the Genitourinary System Flashcards
What are the two types of urinary tract infection?
Lower UTI:
- urethritis (inflammation of the urethra)
- cystitis (inflammation of the bladder)
Upper UTI:
- pyelitis (inflammation of renal pelvis)
- pyelonephritis (inflammation of the kidneys)
Describe the condition of a lower urinary tract infection, including defifnition, risk factors, aetiology, and symptoms
Classifications:
- urethritis (inflammation of urethra)
- cystitis (inflammation of bladder)
Definition:
- more than 100,000 organisms per mL in a mid-urine stream
Risk factors:
- female (shorter urethra, no prostatic secretions)
- pregnancy
- sexual activity
- changes in balance of commensal organisms of perineum / genital tract
Aetiology:
- bacteria (usually E.coli) move from bowel to perineum to urethra
- some bacterial species have pili (hair like crampons that climb up tract)
SSX - urethritis:
- abrupt onset urinary frequency and scalding dysuria
SSX - cystitis:
- suprapubic pain during / after voiding
- tenderness on bladder palpation
- inflammation and spasm results in sensation that bladder is not empty
SSX - both:
- smelly & cloudy urine
- sometimes: gross haematuria
- rare: fever
- elderly: fewer features, confusion
Which bacteria is the most common cause of urinary tract infections?
E.coli (some have pili to climb up urinary tract)
Describe the condition of an upper urinary tract infection including definitions, aetiology, pathophysiology, symptoms and management
Definition:
- pyelitis: inflammation of renal pelvis
- pyelonephritis: inflammation of kidneys
Aetiology:
- lower urinary tract infection can ascend up urethra to infect upper urinary tract (if bacteria have pili and/or if vesico-uretric valves are incompetent)
- rare: blood born infection (usually staph)
Pathophysiology:
- pyelitis occurs first
- infection can spread to kidney (pyelonephritis) causing an acute inflammatory reaction
SSX:
- SSX original cystitis:
- urinary frequency and scalding dysuria
- cloudy and smelly urine - Systemic:
- fever
- rigours
- nausea and vomiting - Upper UTI:
- sudden onset unilateral or bilateral loin pain, maybe radiating to iliac fossa / groin
- tenderness and guarding in renal angle / Lx region
Management:
- antibiotic therapy
- education (void after sexual activity)
- modify risk factors
Describe the condition of nephrolithiasis
Definition:
- also called renal calculi (kidney stones)
- stones formed by masses of minerals and proteins form in kidney
Types of stone:
- calcium oxalate and phosphate (75-85%)
- uric acid (5-10%)
- struvite or cystine (5-10%)
Risk factors:
- highly concentrated urine (dehydration, sweating, heat)
- diseases associated with increased stone forming minerals (gout, hyperparathyroidism)
- increased dietary intake of stone forming minerals (oxalate rich foods, purine rich foods)
- chronic diseases (diabetes, HTN, obesity, CKD)
Pathophysiology (calcium oxalate stones)
- begin as deposits of calcium phosphate in sub-endothelial space around renal papilla (called Randall’s plaque)
- plaques extrude into urinary lumen and act as nuclei for crystal overgrowth
- aggregation causes formation of discrete stones
- stones can have very rough surfaces and cause severe pain
Complications:
- uretric impaction causing renal colic
- sharp severe pain radiating to groin / testes / labia
- distress, pallor, crying, sweating, vomiting
- can cause hydronephrosis and permanent damage - uretric referred pain
- sharp stabbing pain in uretric pathway
- T11-L2 segments via visceral afferents
- projection through genitofemoral nerve (L1-2) causes pain in proximal thigh, scrotum, labia majora - Neoplasia
- large stones can irritate renal epithelium causing metaplasia and then squamous cell carcinoma
SSX:
- insidious onset dull flank pain, maybe radiating to groin
- pain aggravated by urination
- uretric referred pain if ureters obstructed
- maybe haematuria / stony fragments in urine
What are the differences in symptoms between lower urinary tract infections, upper urinary tract infections, and nephrolithiasis?
Urinary:
- lower and upper UTIs: urinary frequency and scalding dysuria, cloudy and smelly urine
- nephrolithiasis: maybe haematuria, stony fragments in urine
Pain:
- lower: urethritis has pain only during urination, cystitis has suprapubic pain during / after voiding
- upper: sudden onset unilalteral or bilateral loin pain, maybe radiating to iliac fossa / groin
- nephrolithiasis: insidious onset dull flank pain maybe radiating to groin and aggravated by urination; uretric referred pain to proximal anterior thigh, scrotum, labia majora if ureters impacted
Systemic:
- lower UTI: none
- upper UTI: fever, rigors, nausea, vomiting
- nephrolithiasis: none
- nephrolithiasi with uretric impaction: distress pallor, sweating, vomiting, groaning, crying
Describe the condition of hydronephrosis
Definition:
- swelling of kidney due to build up of urine
Aetiology:
- caused by obstruction of urine flow
- usually caused by nephrolithiasis
SSX:
- uretric referred pain (sharp severe pain projecting to proximal anterior thigh, scrotum, labia majora via genitofemoral nerve; projecting to dermatomes T11-L2 via visceral afferents)
Management:
- pain management
- reduce concentration of stone forming substances (increase hydration, decrease dietary intake of oxalate and purine rich foods)
- remove stones (ureteroscopy or lithotripsy)
Describe uretric referred pain
- sharp stabbing pain in ureter pathway
Visceral afferents:
- visceral referred pain to dermatomes of T11-L2
Genitofemoral nerve:
- referred pain to proximal anterior thigh, scrotum, labia majora
Which foods increase the risk of developing nephrolithiasis?
Oxalate rich foods
- rhubarb, strawberries, chocolate, nuts, spinach
Purine rich foods
- seafood, liver
What is chronic kidney disease?
Definition:
- progressive loss of kidney function (over months - years)
- mild: GFR 60-89 mL/min
- kidney failulre: GFR less than 15 mL/min
Incidence:
- 7th most common cause of death in Australia
Risk factors:
- family Hx
- age over 50
- obesity, HTN, diabetes, tobacco
Aetiology:
- complication of systemic disease (HTN, diabetes)
- secondary to renal disease (chronic pyelonephritis, chronic glomerulonephritis)
Pathophysiology:
- intact nephrons compensate for damaged nephrons by undergoing expansion and performing hyperfiltration
- this causes further nephron damage and end stage diseases
- pathological processes: progressive glomerular HTN, hyperfiltration and hypertrophy
SSX:
- Systemic SSX caused by declining renal function, accumulation of nitrogenous wastes and toxins, and electrolyte imbalance
- anaemia (pallor, lethargy, breathlessness)
- GIT (anorexia, nausea, vomiting, diarrhoea)
- skin (pigmentation, pruritis) - neuromuscular SSX caused by disturbed calcium and phosphate metabolism
- bone pain and increased fracture risk
- muscle weakness
- myalgia and arthralgia
- peripheral neuropathy
- cognitive and behavioural affects
- neuromuscular irritation (cramps, twitches)
Management:
- dietary
- medications (anti-hypertensive, vit. D, EPO replacement)
- dialysis
- renal transplant
Describe the condition of acute kidney injury (AKI)
Definition:
- sudden decline in kidney function over hours to days
Classifications:
- prerenal
- caused by impaired renal blood flow
- caused by hypovolaemia and / or renal hypoperfusion (CKD, cardiac failure, NSAID overdose, severe vomiting / diarrhea) - intrarenal
- caused by nephron damage (nephrotoxins, malignant hypertension, tumours) - postrenal
- caused by urinary tract obstruction (nephrolithiasis, prostate enlargement, tumours)
Describe the condition of bladder cancer
Types:
- 90% are transitional cell carcinomas (TCCs)
- 98% are primary tumours
Incidence:
- 2nd most common urologic cancer after prostate
- median age diagnosis 69 y.o.
Risk factors:
- family history
- male
- age
- tobacco
Pathophysiology:
- deactivated TP53 (tumour suppressor gene) and increased chromosome oncogene FGFR3 (tyrosine kinase activity)
- TCCs start at base of bladder
- malignancy can progress to underlying muscularis layer and invade othere tissues
SSX:
- urinary (haematuria in 90% of patients, urinary frequency and urgency, leakage)
- pain (suprapubic or perineal, uretric referred if ureters obstructed)
- systemic (fatigue, weight loss, anorexia)
- clinical (maybe palpable abdo mass, hepatomegaly / splenomegaly if metastatic spread)
- often asymptomatic in early stages and mistaken for UTI / nephrolithiasis
Treatment:
- diagnosis (cystoscopy / biopsy)
- low stage disease: TURBT and intravesical chemo
- high stage disease: cystectomy combined with radio and / or chemotherapy
Describe the condition of kidney cancer
Definition:
- 90% are renal cell carcinomas (RCCs)
- Stage 1: in kidney, under 7cm
- Stage 2: in kidney, over 7cm
- Stage 3: spreading to ureters, IVC
- Stage 4: spreading to ureters, IVC, lymph nodes, other organs
Incidence:
- 6th most common cancer in men and 11th in women
- peak age diagnosis 50-60
Prognosis:
- for low stage RCCs surgically removed: 90-100% 5 year survival
- if spread to lymph nodes: usually fatl
Risk factors:
- family history
- male
- tobacco
- CKD
- obesity, HTN
- exposure to chemicals
Pathophysiology:
- RCCs arise from epithelial cells lining renal tubules (usually in poles)
- in 10% of cases RCCs invade renal vein
- in IVC, may grow as a solid column of cells extending upwards
SSX:
- usually asymptomatic until late
- haematuria
- flank pain
- maybe palpable abdo mass
- systemic (weight loss, night sweats, fever)
Management:
- nephrectomy
- radiofrequency ablation and cryoablation
What are the differences in symptoms between bladder and kidney cancer?
Pain:
- kidney: flank pain
- bladder: suprapubic or perineal, uretric referred if ureters obstructed
Urinary:
- both: haematuria
- bladder: urinary frequency, urgency, leakage
