KUB Flashcards
Lower urinary tract symptoms (LUTS) can be classified into storage, voiding and post-micturition symptoms; state some examples of each
Storage
- Urgency
- Frequency
- Nocturia
- Urge incontinence
- Nocturnal enuresis
Voiding
- Dysuria
- Hesitancy
- Poor flow
- Spraying
- Terminal dribbling
- Haematuria
- Incomplete voiding/emptying
Post-micturition
- Post-micturition dribble
What is the difference between terminal dribble & post-micturition dribble?
- Terminal dribble= dribble/still passing small amounts of urine immediately after urinating (i.e. not left toilet yet)
- Post-micturition dribble= dribble/still passing small amounts of urine after leaving toilet as thought they had finished urinating (often end up wet)
State some potential causes of LUTS in men and in women
What investigations would you consider if a pt is presenting with LUTs?
- Urine dipstick (?infection)
- Urine sample for MC&S (?infection?)
- DRE (?prostrate issue)
- Flow rate
- Post-void bladder scan
- Routine blood tests:
- FBC (?infection, baseline)
- U&Es (renal func)
- PSA (?prostrate)
- Specialist investigations:
- Urodynamic studies
- Cystoscopy (GOLD STANDARD)
- Upper urinary tract imaging via USS or Ct
Management of LUTs depends on underlying cause; however, there are some conservative measures that we can suggest to pts. State some of these conservative measures
- Regulating fluid intake
- Not excessive fluids
- Reduce caffeine
- Reduce alcohol
- If have voiding symptoms may benefit from:
- Urethral milking technques (manually empty the bulbar urethra of residual urine)
- Double voiding
- If have stress incontinence or post-micturition dribble:
- Pelvic floor exercises
- If have frequency or OAB symptoms:
- Bladder training
State some potential complications of untreated LUTs
- Infection (stagnation of urine)
- Renal & bladder calculi (stagnation of urine)
- Overflow incontinence
- Bilateral hydronephrosis
- Urinary retention
- Renal failure
Define nocturnal polyuria
State some causes of nocturnal polyuria
- Passing 1/3 or more of total urine output for 24hrs between time of falling asleep and time of waking up
- Often non-urological e.g. diabetes, heart failure, OSA
- Can give desmopressin (vasopressin analogue)
Discuss the classification of haematuria
- Visible
- Non-visible
- Symptomatic non-visible
- Asymptomatic non-visible
What is pseudohaematuria?
- Red or brown urine not due to presence of Hb in urine
- Causes:
- Medications e.g. rifampicin
- Myoglobinuria
- Foods e.g. beetroot, rhubarb
- Hyperbilirubinuria
State some common causes of heamaturia
-
UTI
- Pyelonephritis
- Cystitis
- Prostatitis
- Renal tract stones
-
Malignancy
- Renal cell carcinoma
- Urothelial carcinoma
- Adenocarcinoma of prostrate
- BPH
- Trauma or recent surgery
- Parasitic (most commonly schistomiasis)
State some questions you must ask if someone presents with haematuria
What examinations should you do?
- Degree of haematuria e.g. colour of urine
- Presence of clots
- Timing
- Beginning suggests urethral source
- Total suggests bladder or upper tract source
- Terminal suggests bladder irritation
- Associated symptoms
- Recent trauma
- Drug history
- Smoking status (risk factor malignancy)
- Industrial carcinogen exposure (risk factor malignancy)
- Foreign travel (increased shcistomiasis risk)
Do abdominal examination & DRE
What investigations should be done if someone presents with haematuria?
Initial
- Urine dipstick
- Baseline bloods (FBC, U&Es, CRP, clotting, group & save, ?PSA)
Further management
- US KUB: identify tumours, cysts, hydronephrosis
- CT urogram: identify masses, filling defects etc..
- Flexible cystoscopy: visualise bladder **GOLD STANDARD
What value does urine dipstick have to be to constitute haematuria?
=/> +1
*Trace does not count as haematuria
Discuss the NICE guidelines for urgent referral via 2 week cancer referral pathway to adult urological services for specialist haematuira investigation
- >/=45 yrs with either:
- Unexplained visible haematuria without UTI
- Visible haematuria that persists or recurs after successful treatment of UTI
- >/= 60yrs with unexplained non-visible haematuria and either:
- Dysuria
- Raised WCC on blood test
Urinary retention can be acute, chronic or acute on chronic; true or false?
True
State some causes of acute urinary retention
- BPH (most common cause in men)
- Urethral strictures
- Prostrate cancer
- UTIs (can cause urethral sphincter to close especially in those with already narrowed outflow tracts)
- Constipation (can compress urethra)
- Medications
- Antimuscurinics
- Spinal or epidural anaesthesia
- Neurological causes
- UMN disease
- Bladder sphincter dysinergy
Describe the typical presentation of acute urinary retention
- Acute onset
- Suprapubic pain
- Inability to micturate
- Other features associated with underlying cause
- Palpable distended bladder
- Suprapubic tenderness
For acute on chronic urinary retention, discuss:
- Pathophysiology
- Presentation
- Management
- Either acute deterioration in underlying pathology that causes their chronic retention or a new aetiology on background of chronic retention
- Minimal discomfort despite large residual volumes
- Manage same as acute retention but may have higher residual volumes so at increased risk of post-obstructive diuresis
What investigations should you do if you suspect acute urinary retention?
- Post-void bladder scan
- Routine bloods (especially FBC, U&Es, CRP)
- CSU (catheterised specimen of urine) sent for MC&S
- US of KUB to assess for associated hydronephrosis if high pressure retention
- NOTE: if hydronephrosis present need repeat imaging in few weeks after treatment to ensure resolution
Discuss the management of acute urinary retention
-
Immediate urethral catheterisation
- ***MUST MEASURE VOLUME
- If pt has large retention volume (>1000mL) must monitor for post-obstructive diuresis. If this occurs will need IV fluids replacing 50% of what they are loosing
-
Treat underlying causes
- May need to keep catheter in until cause is treated
What is post-obstructive diuresis?
Clinical criteria?
Management?
- Kidneys over diurese following resolution of retention via catheterisation (due to loss of medullary concentration gradient so kidneys can’t cocentrate urine)
- The volume produced is more than 200mL of urine production per hour for 2 consecutive hours or more than 3 L of urine is produced in 24 hours
- Have 50% of urine output replaced with IV fluids to avoid AKI
State some complications of acute urinary retention
- AKI
- Multiple episodes may lead to scarring & CKD
- Increased risk UTIs
- Increased risk renal tract stones
Some pts with chronic urinary retention may be passing small quantities of urine however still have significant residual volumes. Is this still classes as chronic urinary retention?
YES! because have high residual volumes/still retaining chronically
State some causes of chronic urinary retention- think about different causes for men & women
- BPH (males)
- Urethral strictures
- Prostrate cancer (males)
- Pelvic prolpase (females)
- Pelvic masses (females) e.g. large fibroids
- Neurolgoical causes e.g. UMN (MS, Parkinson’s)
Describe the typical presentation of pts with chronic urinary retention
- Painless urinary retention
- Associated LUTs
- Overflow incontinence
- Nocturnal enuresis (worsening of overflow incontinence at night due to reduced sphincter tone)
- Palpable distended bladder
What investigations are required in suspeted chronic uriinary retention?
- Post-void bladder scan
- Catheter sample for MC&S
- Routine bloods (FBC, CRP, U&Es)
- If have high pressure retention, US of urinary tract (assess hydronephrosis)
Discuss the management of chronic urinary retention
- Catheterise
- Monitor for post-obstructive diuresis
- Definitive management depends on underlying cause. May include some form of long term catheter e.g. ISC or suprapubic
State some potential complications of chronic urinary retention
- Increased risk of UTIs
- Increased risk of bladder calculi
- Repeated episodes of high pressure retention may lead to CKD
Who is urolithiasis more common in?
Males
<65yrs
Explain the difference between kidney stones & ureteric stones
- Kidney= in kidney
- Ureteric= in ureter
Renal tract stones can be made of various substances; state some possible substances including which are most common
- Calcium (80%)
- Calcium oxalate (35%)
- Calcium phosphate (10%)
- Mixed (35%)
- Struvite/magnesium ammonium phosphat
- Urate
- Cystine
Which renal tract stones are the ony radiolucent stones?
Urate
Which type of renal tract stones (calcium, urate, struvate, cystine) are the most common cause of staghorn calculi?
Struvite (often large, soft, staghorn)
Discuss the pathophysiology of urinary tract stones
- Over-saturation of urine (with the substance that forms the stone)
- Certain stone types may be caused by specific underlying pathology e.g.
- Urate stones due to high level purine in blood
- Diet
- Haematological disorders e.g. myeloproliferative disease
- Cystine
- Homocystinuria
- Urate stones due to high level purine in blood
Why can hypocitraturia predispose to urolithiasis?
State 3 places urinary tract stones are likley to be impact (due to the structures being narrow)
- Pelviureteric junction
- Pelvic brim (where iliac vessels travel across ureter in the pelvis)
- Vesicoureteric junction
State clinical features of renal tract stones
-
Pain “ureteric colic” (most common symptom but also possible to not have pain especially if stone not obstructing)
- Sudden onset
- Loin to groin pain
- Nausea & vomitting (associated with pain)
- Haematuria (typically non visible)
- Signs of infection (fever, lethargy etc…)
- Renal flank tenderness
*Get pain due to increased peristalsis around site of obstruction
What investigations are required if you suspect renal tract stones?
Bedside
- Urine dip:may find haematuria +/- leucocytes. If thinking infection send urine culture
- Stone analysis (if passed stone)
Bloods
- FBC: ?infection
- CRP: ?infection
- U&E’s: renal function
- Urate levels: ?cause of stone
- Calcium levels:?cause of stone
- Blood cultures: pyrexial and ?sepsis
- Coagulation: if percutaneous intervention planned
Imaging
- Non-contrast CT KUB: GOLD STANDARD. Recommended 1st line by BAUS. All should have within 14hrs of admission (see next FC for some exceptions)
- Plain film abdo radiographs:
- USS: assess for hydronephrosis
BAUS say that everyone with ?renal stones should have non-contrast CT KUB within 14hrs of admission; which patients should have immediate non-contrast CT KUB?
If patient has any of:
- fever
- a solitary kidney
- or when the diagnosis is uncertain an immediate CT KUB should be performed
Explain the advantages & disadvantages of following imaging modalities in assessing potential urolithiasis:
- Non-contrast CT KUB
- Plain film abdo radiograph
- Intravenous urograms
- USS of renal tract
Non-contrast CT KUB
- __Gold standard
- High sensitivity & specifiity
- Good at detecting stones and any alternative pathology that may also be present
Plain film abdo radiograph
- Not all stones are radio-opaque (urate stones= radiolucent)
Intravenous urograms
- Inject contrast and take series of abdo x-rays and look for filling defect
- High radiation
- CT still superior
USS of renal tract
- Can detect some stones (NOT ureteric stones)
- Operator dependent
- No radiation risk
Discuss the initial management of renal tract stones
Most stones pass spontaneously (particulary if in lower ureter or <5mm diameter) hence initial management is supportive:
- Fluid resuscitation if required (pts often dehydrated)
- Analgesia (opiates & rectal NSAIDs often most effective)
- ?IV abx if evidence of significant infection (and refer to urology)
State the criteria for inpatient admission with renal tract stones
- Post-obstructive AKI
- Uncontrollable pain
- Evidence of infected stone(s) or significant infection
- Large stone >5mm
If a pt presents with evidence of obstructive uropathy or significant infection what may they require alongside intial management and hospital admission?
Stent insertion or nephrostomy to relieve obstruction and prevent renal damage:
- Retrograde stent insertion: place stent in ureter via cystoscopy to keep ureter open
- Nephrostomy: tube placed directly into renal pelvis & collecting system and connected to external drainage bag. Can also pass anterograde stent at same time
Discuss the definitive mangement of renal tract stones if they do not pass spontaneously
Numerous options:
-
Extracorpeal shock wave lithotripsy (ESWL):
- Uses ultrasound waves to break up the stone
- Segments/fragments of stone can tehn be passed
- Small stones <2cm
- Done under radiological guidance (x-ray or USS)
-
Percutaneous nephrolithotomy:
- Percutaneous access to kidney
- Place nephroscope int o renal pelvis
- Fragement stones using various forms of lithotripsy
- RENAL STONES ONLY
- Preferred for large stones
-
Flexible uretero-renoscopy (URS):
- Pass scope into ureter (retrograde)
- Fragment stones using laser lithotripsy
- Used if <2cm and pregnant
- Subsequent removal of fragments
*lithotripsy: using high energy shock waves to break up stones
State some potential complications of renal tract stones
- AKI
- Infection
- Recurrent renal stones lead to renal scarring and loss of kidney function
Patients who recurrently form stones can make lifestyle changes to reduce risk of stone formation. Discuss:
- NICE guidance for all those who form renal stones
- Stone specific guidance
- Two medications which can be used to reduce risk of stone formation
NICE guidance 2019 advises all pts to:
- Increase fluid intake (2.5-3L a day)
- Add fresh lemon juice to water (citric acid binds to urinary calcium)
- Avoid carbonated drinks (contain phosphoric acis which promotes oxalate formation)
- Reduce dietary salt intake
- Maintain normal calcium intake
Calcium stone formers:
- check PTH to exlcude primary hyperparathyroidism
Urate stone formers:
- avoid high purine foods
- may need urate lowering medication e.g. allopurinol
Oxalate stone formers:
- avoid high purine foods
- avoid high oxalate foods (e.g. spinach, beetroots, balck tea, nuts, rhubarb, sesame)
Medications
- Potassium citrate (calcium oxalate stones & raised urinary calcium)
- Thiazides (clacium oxalate stones & raised urinary calcium)
State 3 potential causes of bladder stones
How do bladder stones present?
What investigations are required?
What management is required?
What do bladder stones predispose to?
- Causes:
- Chronic urinary retention (bladder stasis)
- Secondary to infection (clasically schistomiasis)
- Due to passed ureteric stones that are now stuck in bladder
- Present with lower urinary tract symptoms
- Same investigations as for renal & ureteric stones
- Cystoscopy allowing stones to drain or fragment them with lithotripsy if required
- Chronic irritation can predispose to development of SCC bladder cancer
Remind yourself for pyelonephritis:
- What it is
- Common causative organism
- Presentation
- Investigations
- Management
- Inflammation of kideny parenchyma & renal pelvis typically due to infection
- Organsims:
- Escherichia coli (80%)
- Staphylococcus aureus (catheters)
- Staphylococcus saprophyticus (commensal)
- Psueodmonas aeruginosa (catheters)
- Classic triad: fever, loin pain, nausea & vomitting
- Investigations:
- Urinalysis
- Urine culture
- Bloods: FBC, CRP, U&Es
- Renal USS (check for obstruction)
- If obstruction suspected do CT KUB
- Managment:
- Empirical abx
- Analgesia
- Anti-emetics
- Encourage fluid intake
- Consider admission if unstable
- Complications:
- Sepsis
- Pyonephrosis
- Renal scarring leading to CKD
- Pre-term labour
Remind yourself for chronic pyelonephritis:
- What it leads to
- Who common in
- Aims of treatment
- Repeated pyelonephritis/infection of kidneys leading to fibrosis and destruction of kidney parenchyma
- More common in children with obstructed systems
- Treatment:
- Reverse underlying cause
- Optimise renal function
- Consider prophylactic abx
Renal cysts can cause haematuria, for renal cysts dicuss:
- What they are
- Clinical features
- Investigations
- Which cysts have increased risk of malignancy
*
- Fluid filled sacs in kidney. Classified as simple or complex (depending on structure)
- Usually asymptomatic and found incidentally however may present with;
- Flank pain (cyst rupture or infection)
- Haematuria
- Complicated cysts have increased risk of malignancy
- Defintive diagnosis thoruhg CT or MRI kidneys with IV contrast
State some renal malignancies- highlight which is most common in adults
- Renal cell carcinoma (85%) *adenocarcinoma of renal cortex
- Squamous cell carcinomas (chronic inflammation e.g. caliculi, infection)
- Transitional cell carcinoma (urothelial tumours)
- Nephroblastoma (in children- Wilm’s tumour)
Who is RCC common in?
(age, gender)
- 50-70yrs
- Men
State some risk factors for RCC- highlighting the most common
- Smoking (x2)
- Dialysis (x30)
- Hypertension
- Obesity
- Anatomical abnormalities (e.g. polycystic kidneys)
- Genetic disroders (e.g. von Hippel-Lindau)
- Industrial exposure (e.g. aromatic hydrocarbons)
State clinical features of RCC
- Haematuria (visible or non-visible)
- Flank pain
- Non-specific:
- Weight loss
- Fatigue
- Anorexia
- Night sweats
- Flank mass
- May have left-sided varicocoele (compression of L testicular vein as joints L renal vein)
*NOTE: only 50% symptomatic. May also present with paraneoplastic syndromes e.g. polycythaemia (erythopoetin), hypercalcaemia (PTH), hypertension (renin).
Discuss what investigations are required for RCC
Beside
- Dipstick
- Urine sample (cytology)
Bloods
- FBC (rule out infection, polycythaemia)
- CRP (rule out infection)
- U&Es (renal func)
- Calcium (paraneoplastic syndrome)
- LFTs
Imaging
- USS renal
- CT abdomen-pelvis pre and post IV contrast *GOLD STANDARD
Discuss the management of:
- Localised RCC
- Metastatic RCC
Localised
- Surgery is mainstay: partial or radical nephrectomy
- If not fit surgery: percutaenous radiofrequency ablation or cyrotherapy
Metastatic
- Nephrectomy with immunotherapy
- Biological agents
- Metasasectomy (surgical resection of solitary masses)
Discuss prognosis of RCC
- 25% have mets at presentation
- 70% survival at 3 years
What cancer is the most common cancer of the urinary system?
Bladder
Who is bladder cancer common in?
(include age & gender)
men
>80yrs
Remind yourself of the 4 layers of bladder wall
Transitional epithelium (urothelium)
Lamina propria
Muscularis propria (detrusor muscle)
Fatty connective tissue layer
State some subtypes of bladder cancer- highlighting which is most common
- Transitional carcinoma (80-90%)
- Squamous cell carcinoma
- Adenocarcinoma (rare)
Bladder cancer can be further classified into:
- Non-muscle invasive (70-80%)
- Muscle invasive
- Locally advanced or metastatic
State some risk factors for bladder cancer -highlighting the most important (2)
- Smoking
- Increasing age
- Industrial exposure (e.g. aromatic hydrocarbons)
- Previous pelvic radiation
- Schistosomiasis (SCC subtype)
State clinical features of bladder cancer
- PAINLESS haematuria (visible or non-visible)
- Recurrent UTIs (cancer acts as nidus for infection)
- Storage symptoms:
- Frequency
- Urgency
- Feeling of incomplete voiding
- Systemic symtpoms:
- Weight loss
- Lethargy
- If locally advanced may have pelvic pain
What staging is used for both renal & bladder cancer?
TNM
T= size of primary tumour (T1-T4)
N= extension of regional node metastases via lymphatics (NO-N3)
M= extent of distant metastatic spread via blood (M0 - M1)
What investigations are required for suspected bladder cancer?
*IF present with haematuria do usual workup
Bedside
- Urine dipstick
- Urine sample (Culture & cytology. NOTE cytology not always routinely done)
Bloods
- FBC
- CRP
- U&Es
Imaging
- USS
- Cystoscopy (first flexible under LA then rigid under GA if want to take biopsies & TURP)
- CT abdo pelvis
Discuss the management of non-muscle-invasive bladder cancer
- TURBT (transurethral resection of bladder tumour)
- If higher risk may also have adjuvant intravesical therapy e.g with Mitomycin C
- If high risk and limited respose to initial treatment do radical cystectomy
- Regular follow ups- cytology & cystoscopy- as high rate of reoccurence (and reoccurence likely more invasive)
What is TURP?
When is it done?
- Transurethral resection of bladder: uses diathermy to resect bladder
- Done during rigid cystoscopy
- Take biopsies at same time
- TURP may be done during intial cystoscopy if surgeon thinks it’s superficial or be done following biopsy results if thinks it may be invasive
Discuss the management of muscle invasive bladder cancer
-
Radical cystectomy with urinary diversion:
- Ileal conduit formation with urine draining via urostomy
- Bladder reconstruction using segment of small bowel with urine draining urethrally or via catheter
- Consider neoadjuvant chemotherapy
Discuss the managent of locally advanced or metastatic bladder cancer
- Chemotherapy
- MDT management
- Palliative care
Why must you check B12 & folate at least annully in pts who had radical cystectomy and urinary diversion?
Resected part of ileum
Ileum absorbs B12 and folate
Discuss the prognosis of bladder cancer
- Increased risk of developing upper urinary tract tumours & urethral tumours
- If superficial disease 5yr survival is 80-90% (but survival depends on staging)
Incontinence is the involuntary leakage of urine; remind yourself of the subtypes of incontinence
- Stress
- Urgency
- Mixed
- Overflow
- Continuous
Discuss for each of the subtypes of incontinence pathophysiology, causes/RF, presentation:
- Stress
- Urgency
- Mixed
- Overflow
- Continuous
Stress
- Intra-abdominal pressure > uretheral sphincter pressure
- Impaired urethral support most commonly due to weakness of pelvic floor muscles
- Leakage during cough, straining, laughing or lifting
- RF: post-partum, constipation, obesity, post-menopause, pelvic surgery
Urge
- Overactive bladder/detrusor hyperactivity leading to unhibited bladder contraction, a rise in intravesical pressure, leakage of urine
- Sudden urge to go, don’t make it to toilet in time
- Causes: neurogenic, infection, malignancy, idiopathic, cholinesterase inhibitors
Mixed
- Combination of stress & urge
Overflow
- Chronic retention leads to progressive stretching of bladder wall leads to loss of bladder sensation and damage to efferent fibres of sacral reflex. This results in bladder filling with urine and becoming grossly disteneded. Intravesicle pressure increases and is > urethral sphincter pressure leading to leakage of urine
- Causes: complication of chronic urinary retention, BPH, spinal cord injuries
Continuous
- Constant leakage of urine
- Anatomical abnormality e.g. ectopic ureter, bladder fistula or due to severe overflow incontinence
What investigations should you do for pts with urinary incontinence?
Bedside
- Ask pt to keep bladder diary
- Urine dipstick (infection can mimic incontinence)
- Post-void bladder scan
Further investigations that may be considered:
- Urodyanamic assessment (measure intravesicular and intra-abdominal pressure to calculate detrusor pressure. Hyperactivity may suggest urge)
- Can also do outlfow urodynamics (measure detrusor activity against urine flow rate. High intravesicle pressure with weak stream suggest overflow)
- Cystoscopy
- MRI
Discuss the management of stress UI
- Lifestyle advice
- Reduce caffeine
- Weight loss
- Avoid drinking excessive volumes
- Smoking cessation
- Supervised pelvic floor muscle training. Do 3x daily for at least 3 months
- If above doesn’t work or pt unsuitable, duloxetine (serotonin-noradrenaline reuptake inhibitor) can be trialled- causes stronger urethral contraction. *Consultant said doesn’t work very well
- Surgical:
- Vaginal tape
- Autologous sling (using rectal fascia)
- Intramural bulking agents (50-60% success)
- Colposuspension
- Artificial urinary sphincter
Discuss the management of urge UI
Conservative
- Lifestyle advice:
- Reduce caffeine intake
- Weight loss
- Avoid drinking excessive volumes each day
- Smoking cessation
- Bladder training for minimum 6 weeks
Pharmacological
- Oxybutynin (anti-muscuranic drugs) to inhibit detrusor contraction
- Mirabegron (beta-3 agonist) used if anticholinergics contraindicated or added as an adjunct. BUT cannot use in uncontrolled hypertension
- Topical vaginal oestrogen in post-menopausal women
Surgical:
- Botulinum toxin A injections (paralyses detrusor muscle)
- Sacral neuromodulation
- Augmentation cystoplasty (works as it disrupts synchronised waves of detrusor contraction)
- Urinary diversion via ileal conduit
What is the difference between overactive bladder syndrome & urgency incontinence?
- Overactive bladder syndrome: group of symptoms in which most common one is when person regularly gets sudden urge to urinate. Caused by detrusor dysfunction/involuntary contractions of detrusor
- Urgency incontinence occurs when the above happens but don’t have time to make to the toilet so are incontinent
HENCE, management of OAB is same as for urgency incontinence
Compare high and low pressure urinary retention
High pressure
- High intravesicle pressure
- High IVP overcomes antireflux mechanism of bladder & ureter
- Urine bakcs up into upper renal tract
- Hydroureter & hydronephrosis
- May have impaired renal function
- Risk of permanent renal scarring & CKD
Low pressure
- Low intravesicl pressure
- Competent uretheral valves or reduced detrusor muscle contractility so pressures stay low
- No hydorureter or hydronephrosis
- Renal fucntion fine
