Lecture 9: Presentations of Diseases of the Kidneys and Urinary Tract Flashcards
which structures compose the upper urinary tract?
Kidneys:
- parenchyma
- pelvi-calyceal system
Ureters:
- pelvi-ureteric junction
- ureter
- vesico-ureteric junction
which structures compose the lower urinary tract?
- bladder
- IUS
- prostate (men)
- EUS
- urethra
- urinary meatus
- foreskin (men)
aetiology of renal diseases
- infection: pyelonephritis
- inflammation: glomerulonephritis, tubulointerstitial nephritis
- iatrogenic: nephrotoxicity, PCNL
- neoplasia: renal tumours, collecting system tumours
- trauma: blunt trauma
- vascular: atherosclerosis, hypertension, diabetes
- hereditary: polycystic kidney disease, nephrotic syndrome
clinical presentation of renal disease
- pain
- pyrexia
- haematuria
- proteinuria
- pyuria (pus in urine)
- mass on palpation
- renal failure
what is considered proteinuria?
urinary protein excretion > 150mg/day
in clinical practise, how many types of haematuria are there?
three
what is considered microscopic haematuria?
> /= 3 red blood cells per high power field
what is considered oliguria?
urine output < 0.5ml/kg/hr
what is considered anuria? absolute and relative
- absolute anuria: no urine output
- relative anuria: < 100ml/24 hours
what is considered polyuria?
urine output > 3L/24 hours
what is considered nocturia?
waking up at night >/= 1 occasion to micturate
what is considered nocturnal polyuria?
nocturnal urine output >1/3 total urine output in 24 hours
which factors should be excluded when investigating polyuria and polydipsia?
- chronic renal failure
- hypokalaemia
- hyperglycaemia
- hypercalcaemia
- thyrotoxicosis
- diuretics
- diet
presentation of chronic renal failure
- asymptomatic (found on blood and urine testing)
- tiredness
- anaemia
- oedema
- high blood pressure
- bone pain due to renal bone disease
in advanced renal failure:
- pruritus
- nausea/vomiting
- dyspnoea
- pericarditis
- neuropathy
- coma (untreated)
presentation of ureteric disease
- pain (e.g. renal colic)
- pyrexia
- haematuria
- palpable mass (i.e. hydronephrosis)
- renal failure (only if bilateral obstruction or single functioning kidney)
presentation of bladder diseases
- pain (suprapubic)
- pyrexia
- haematuria
- recurrent UTIs
- chronic urinary retention
- urinary leak from vagina (i.e. vesico-vaginal fistula)
- pneumaturia (i.e. colo-vesical fistula)
Lower urinary tract symptoms:
- storage i.e. frequency, nocturia, urgency, urge incontinence
- voiding i.e. poor flow, intermittency, terminal dribbling - due to underactive bladder
- incontinence i.e. stress, urge, mixed, overflow, neurogenic, dribbling etc.
what is the risk of bladder cancer in patients with macroscopic haematuria?
25-30%
what is the risk of renal cancer in a patient who presents with macroscopic haematuria?
0.5-1%
list the possible causes of lower urinary tract symptoms (LUCTS) i.e. voiding LUTS, storage LUTS, incontinence polyuria etc.
- bladder pathology: OAB, UTI, interstitial cystitis, bladder cancer
- bladder outflow obstruction
- pelvic floor dysfunction
- neurological causes: supra-pontine lesions (e.g. stroke, alzheimer;s, parkinson’s), infra-pontine supra-sacral lesions (e.g. spinal cord injury, disc prolapse, spina bifida), infra-sacral lesions (e.g. MS, diabetes, cauda equina compression, surgery to tetroperitoneum)
- systemic disorders: chronic renal failure, cardiac failure, diabetes mellitus, diabetes insipidus)
list the areas of the CNS involved in controlling micturition
1) cortical centre (bladder sensation and conscious inhibition of micturition)
2) pons (micturition centre)
3) sacral segments (S2-S4) (micturition reflex) causing:
- relaxation of IUS
- relaxation of EUS
- contraction of detrusor muscle
presentation of bladder outflow tract diseases
- pain (suprapubic or perineal)
- pyrexia
- haematuria
- LUTS
- recurrent UTIs
- acute urinary retention
- chronic urinary retention
define acute urinary retention
painful inability to void urine with palpable and percussible bladder
aetiology of acute urinary retention
- main risk factor: benign prostatic obstruction (BPO)
- UTI
- urethral stricute
- alcohol excess
- post-op causes
- acute surgical or medical problems
what is the immediate treatment for acute urinary retention?
catheterisation
define chronic urinary retention
- painless, palpable and percussible bladder after voiding
- patiebts often able to void but with residuals ranging from 400ml to >2 litres depending on stage of condition.
what is the main aetiological factor in chronic urinary retention?
detrusor muscle underactivity which can be primary (i.e. primary bladder failure) or secondary (i.e. due to longstanding bladder outflow obstruction, such as BPO or urethral stricture)
chronic urinary retention presentation
- LUTS
- complication e.g. UTI, bladder stones, overflow incontinence, post-renal or obstructive renal failure
- asymptomatic, incidental finding
in high-pressure chronic urinary retention, which two types of diuresis may occur?
- physiological (usually < 200ml/hr)
- pathological (usually > 200ml/hr)
treatment of chronic urinary retention
- immediate: catheterisation
- subsequent: long-term urethral or suprapubic catheter, CISC or TURP if due to benign prostatic obstruction (BPO)
what does a diagnosis of a UTI require?
- microbiological evidence: bacteral count of 10^4 cfu/ml from MSSU specimen with no more than two species of micro-organisms.
- symptoms/signs, at least one of the following: fever > 38, loin/flank pain or tenderness, suprapubic pain or tenderness, urinary frequency, urinary urgency, dysuria
what are the two types of UTIs?
- uncomplicated UTIs (young sexually active females only with clear relation to sexual activity)
- complicated UTIs (everyone else, always need to be investigates)
complications of UTIs
- infective: sepsis (esp. pyelonephritis), perinephric abscess
- renal failure (scarring)
- bladder malignancy (squamous cell carcinoma)
- acute urinary retention
- frank haematuria
- bladder or renal stones
UTI investigations
- MSSU/CSU
- lower tract: flow studies, residual bladder scan, cytoscopy
- upper tract: USS kidneys, IVU/CT-KUB, MAG-3 renogram, DMSA scan
UTI treatment
- appropriate antibiotic therapy (type? duration? route?)
- treat complications and cause
list emergencies related to urinary tract diseases
- acute renal failure
- sepsis
- renal colic
- severe haematuria causing haemorrhagic shock
- metastatic disease
- acute urinary retention
- chronic high-pressure urinary retention
- iatrogenic injury/trauma to upper or lower urinaru tract, penis and testis
- testicular torsion
- paraphimosis
- priapism
list the organisms commonly associated with UTIs
- E.coli
- Klebsiella species
- proteus species
- pseudomonas aeruginosa
