general Flashcards
what are the 2 broad categories of urinary tract symptoms in men?
voiding symptoms:
- hesitancy, straining, intermittency and weak stream
Storage symtoms:
- frequency, urgency, incontinence, terminal dribbling
nocturia can be a feature of either group
what is the international prostate symptom score (IPSS)
scoring tool - rapidly diagnose, track the symptoms of, and suggest management of symptoms BPH
8 Q’s exploring incomplete emptying, frequency, intermittency, urgency, weak stream, straining, nocturne, quality of life
what Ix would be involved in someone presenting with urinary symptoms
examine:
- abdo (palpable bladder or constipation)
- peripheral oedema (along with frequency and nocturia suggests a cardiac cause)
- external genitalia (phimosis or obvious mental stenosis)
- perform DRE (size of prostate; enlarged >30g/golf ball size)
perform urinalysis
describe the innervation of the bladder
- SNS, via hypogastric n., causes relaxation of the detrusor muscle and urine retention
- pelvic splanchnic nn. promote micturition (contraction of the detrusor muscle), and relaxation of the internal urethral sphincter re
- afferent nn, involved in the bladder stretch reflex. when full the muscle wall stretches and the sensory info is transmitted to the SC and relayed to PSN efferents via interneurons to stimulate micturition
describe how the urine is transported from the kidneys to the bladder
collecting ducts -> renal calyces (stretches them and increases their inherent pacemaker activity, which initiates peristaltic contractions that spread to) -> renal pelvis -> ureter -> bladder
smooth muscle of the ureter is innervated by SNS (decreases peristalsis) and PNS (increases peristalsis)
normal tone of the detrusor muscle tends to compress the ureter, thereby preventing back flow. will open when pressure is generated by peristalsis waves
describe the micturition reflex
the bladder’s smooth muscle has some inherent contractile activity; however, stretch receptors in the bladder wall initiate a reflex contraction that has a lower threshold.
- sensory signals send to sacral spinal cord via somatic afferents
- reflex back to bladder via parasympathetic fibres in the same nerve and cause detrusor contraction
3a. when only partially full these contractions relax spontaneously
3b. as bladder fills, the reflex is more frequent and causes greater contraction - reflex is self-regenerative and repeats until a strong contraction is achieved, after a few seconds it starts to fatigue and bladder relaxes (MR = a cycle of 1) progressive and rapid increase of pressure 2) a period of sustained pressure and 3) return of the pressure to the basal tone)
- as bladder gets fuller the MR becomes more often and more powerful
- once it becomes powerful enough, it causes another reflex which passes through the pudendal n., to external sphincter to inhibit it. if this inhibition is more potent in the brain the voluntary constrictor signals urination. if not, the bladder fills until MR is more powerful
list 3 abnormalities of micturition
- neurogenic bladder:
- results in frequent and relatively uncontrolled micturition
- partial damage in the SC or brain stem that interrupts most of the inhibitory signals
- common in MS, Parkinsons, diabetes - atonic bladder:
- destruction of sensory nerve fibres
- no MR despite intact efferents
- instead of emptying periodically, the bladder fills to capacity and overflows a few drops at a time - autonomic bladder:
- SCI above sacral region
- reflex can still happen but not controlled by the brain
- will empty periodically but unannounced
along with urological anatomy, what 5 ‘topics’ will help with a diagnosis?
- trauma
- swelling (non-neoplastic, benign, malignant)
- chronic (inflammation)
acute (infection, acute toxic, immunological) - stone (genetic, metabolic)
what is the function of the kidneys?
- fluid anf electrolyte balance
- resorption of solutes
- excretion e.g. of conjugated xenobiotics
- endocrine (renin - blood pressure; erythropoietin - RBC)
list some of the main congenital and genetic condition affecting the kidney
- cystic disease
- heavy kidney, destruction of kidney by cystic dilations, get scarring
- present with pain (simply because of size), haematuria (haemorrhage into cyst), secondary infection, hypertension
- different subtypes (AD and AR etc)
- mainly common in adults, rare in children - bi/unilateral agenesis of the kidney
- hypertension
- haematuria
- proteinuria - alports syndrome:
- triad of hearing loss, eye abnormalities and kidney disease
- genetic - autosomal dominant RCC
why do you get hyperlipidemia and oedema in nephrotic syndrome?
hyperlipidemia:
compensatory synthesis of proteins (including lipoproteins) by the liver
oedema:
- decrease in oncotic pressure -> fluid escapes into tissues
- decrease in oncotic pressure -> decrease in plasma volume -> decrease in GFR -> increase in aldosterone secretion -> fluid retention -> oedema
compare nephrotic and nephritic syndrome
nephrotic:
- caused by glomerular disease (e.g. minimal change disease) or damage (e.g. diabetes)
- glomerular damage leads to increased permeability of glomerular capillaries to protein -> proteinuria -> hypoproteinemia -> hyperlipidemia and oedema
- proteinuria, oedema, hyperlipadaemia, frothy urine, anti-tIII is lost (hyercoagulation)
nephritic: - inflammatory condition (antigen-antibody complexes damage e.g. from post-strep infection, small vessel vasculitis) - instead of lots of fats and oedema you have: pain haematuria (less) proteinuria (cola urine) and oliguria/pass lead urine HTN oedema
discuss urinary calculi
- kidney stones
- can be acute or chronic
- can get into the ureter –> colic or spasm. very painful
- may cause secondary infection –> pyelonephritis which can extend right up into kidney parenchyma
- haematuria
- obstructive uropathy -> hydronephrosis
- post-renal renal failure
different types:
- 75% are calcium stones (hypercalcaemia)
- 20% are uric acid (gout)
- infection (obstruction)
- cystine (genetic, dehydration)
list possible causes of bladder disease
- inflammation
- can be acute of chronic
- cystitis is inflammation of the bladder, usually caused by a bacterial infection (also reaction to drugs, radiation therapy or potential irritants)
- lots of neutrophils, dilated blood vessels - infection
- uti
- most causes are acute - calculi
- can form in the bladder
- can damage mucosa curing secondary infection and haematuria - neoplasm:
- most common is transitional cell carcinoma
- presentation = haematuria (even once is significant), dysuria, obstruction
what are common urinary tract neoplasms
prostate - adenocarcinoma
bladder - urotheloal (transitional cell) carcinoma
renal :
- 4/5 are clear cell carcinomas
- originates in ducts esp PCT and pushes out
- mostly sporadic, but related to smoking and obesity
- may present late. kidney remains there and functioning - normal eGFR. can present with pain, fever
- difficult surgically as can grow along renal v. into IVC -> heart or directly into blood, trap in liver
- 50% 5 yr survival, but stage dependant
- M>W, haematuria MC symptoms, mass, pain, mets, paraneoplastic syndromes (eg pyrexia)
what are the rarer urinary tract tumours?
renal carcinomas other than clear cell
renal nephrobastoma (Wilms Tumour):
- children 👶 < 3y/o
- present with large abdominal mass, unilateral, painless
- mutation in WT1 tumour suppresor gene
- 90% survival; surgery, radio, chemo
ureter transitional cell carcinoma
renal/bladder sarcoma
why is bladder usually cancer not a single tumour?
it is a change that happens across the entire mucosa. why? most carcinogens e.g. cigarette smoke are concentrated in the urine. all the mucosal epithelium is exposed and therefore at risk
*also tends to reoccur
discuss the causes and effects of AKI and CKI
acute:
- pre-renal cause (hypovolemia, increase vascular capacity and leakage, heart is compromised, renal stenosis)
- renal cause (ATN, interstitial nephritis, glomerulonephritis)
- post-renal cause (obstruction)
- effects = high potassium, high creatinine, may be oliguria, HTN, (lipids in nephrotic syndrome)
chronic:
- pre-renal cause (atherosclerosis)
- renal cause (glomerulonephritis, diabetes, hypertension, polycystic)
- post-renal (obstruction)
- effects = high potassium, creatinine high, may be oliguria, HTN, anaemia (because kidney parenchyma has been lost, reduction in EPO), small kidneys
list complications of BPH
bilateral hydronephrosis bilateral hydroureter kidney infection, renal failure, calculi, septicaemia bladder diverticulum compression of urethra
a) briefly compare BPH and prostate carcinoma
b) what are the different types of prostate enlargement
a) in part where it arises. hyperplasia arises in prostate transitional zone and carcinoma at the edge of prostate/ peripheral zone. often won’t present with urinary symptoms and prob spread to nearby organs (felt on rectum exam)
b) benign nodular hyperplasia (MC!) = due to hormonal imbalance. the whole prostate (glandular and fibromuscular portions) enlarge. treatable with surgery or hormone manipulation
BPH = enlargement of the transitional zone plus peri-urethral glands. may lead to urinary retention (acute = painful chronic = painless and gradual)
discuss prostate Ca
prostatic intraepithelial neoplasia - is precurser
adenocarcinoma is most common
asymmetric firm enlargement
mets (esp to bone)
Gleason score use to predict prognosis
present with urinary symptoms, incidental finding on rectal exam, bone met, LN met
complications with surgery Mx (impotence, urinary problems)
Dx imaging, US, XR, isotope bone scan, cystoscopy, PSA
Tx oestrogen, GnRH analogue, orchidectomy, radiotherapy, radical prostectomy
explain the effects of uncertainty about diagnosis and prognosis
- uncertainty is a large part of the problem for individual sufferers
- both pre- and post-diagnosis
- before Dx: symptoms present for long time, patient may delay seeing dr, symptoms are non-specific unusual illness course
- after: uncertainty in the short-term i.e. day-to-day fluctuating and long-term i.e. ambiguity as to how pt will respond
apply sociological theories of chronic illness trajectory
different types of condition come under chronic. can be differentiated on trajectory:
- short period of evident decline - we experience a very short but extensive period of decline. e.g. Ca
- long-term limitation with intermittent serious episodes - gradual decline over time e.g. heart or lung failure
- prolonged dwindling - e.g. frailty and dementia
explain what is meant by stigma in relation to illness
a label that invokes a negative social reaction results in stigma - a mark of social disgrace
process of stigma:
- people differentiate/label differences considered socially important
- people thus labelled are placed in different categories
- cultural beliefs link these differences to other attributes, reliant on equally negative stereotypes
- people thus labelled are actually devalued, experiencing loss od status and discrimination
- a process dependent on and perpetuated by the social, economic and political power of those doing the labelling and discriminating
responses:
- passing (trying to bass as normal)
- covering (hiding the condition)
- withdrawal (excluding themselves from situations which could draw attention to stigmatising condition)
- self-fulfilling prophecy (reinforcing the experience and effects)
discuss the inequalities in chronic illness
- unemployment and economic problems:
- common consequence -> Lower income (less resources to support themselves)
- particularly for women
- low social class and minorities
- employment not only important for economic reasons, but gives people purpose - strained family relations:
- family members becoming carers (especially women)
- overburden and excluded by wider social relationships
- emotions involved can be complex. those providing care feel generosity but resentment
- strains on marital relationships; sexual capacity inhibited, physical embarrassment
what is liminality?
sense of being betwixt-and-between
falling in the crack between solid sociological states. e.g. prostate Ca. men have very few cultural scripts to draw on. choices about Tx - options of deferring starting. leaves men in a betwixt and between state
apply sociological theories of chronic illness experience
- biographical disruption :
- conveys way in which peoples perceptions of themselves and life courses is completely derailed
- catalyses process of rethinking about what life is all about and awareness of mortality
- catalyses process of adaption and accommodation which can be divided into 3 (1. coping - cognitive process learning how to tolerate the effects of illness; 2. strategies - actions people take in face of illness; 3. style - the way people respond to and present important features of their illness or treatment regimen) - loss of self:
- the illness impacts on sense of who they are, self esteem/worth
- fundamentally rethink who they are - biographical reconstruction:
- rebuilding of identity, about how pt’s rework their identity incorporating their disease
- strategies people employ to create a sense of coherence, stability and order
- able to incorporate the illness into the fundamental sense of who they are
