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Elderly Years > Pathology of the Urinary Tract > Flashcards

Pathology of the Urinary Tract Flashcards

1
Q

What are the causes of vomiting derived from urinary tract pathology?

A
  • Pyelonephritis
  • Ureteric calculus
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2
Q

What are the causes of penile pain derived from urinary tract pathology?

A
  • Balanitis
  • Urethritis
  • Balanitis xerotica obliterans
  • Prostatitis
  • Herpes simplex virus
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3
Q

What are the causes of penile ulceration derived from urinary tract pathology?

A
  • HSV
  • Balanitis
  • Trauma
  • Balanitis xerotica obliterans
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4
Q

What are the causes of scrotal swelling?

A
  • Inguinal hernia
  • Hydrocele
  • Epididymal cyst
  • Epididymo-orchitis
  • Testicular torsion
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5
Q

What are the causes of urinary frequency derived from urinary tract pathology?

A
  • UTI
  • Detrusor instability
  • Bladder calculus
  • Prostatic hypertrophy
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6
Q

What are the causes of haematuria derived from urinary tract pathology?

A
  • UTI
  • Bladder tumour
  • Renal / ureteric calculi
  • Urethritis
  • Prostatic hyperplasia
  • Prostatic cancer
  • Renal carcinoma
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7
Q

What are the causes of acute abdominal pain derived from urinary tract pathology?

A
  • Stones in the ureter
  • Pyelonephritis
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8
Q

What is the main cause of abdominal swelling derived from urinary tract pathology?

A

Enlarged bladder due to obstruction

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9
Q

What is the commonest cause of chronic abdominal pain derived from urinary tract pathology?

A

Hydronephrosis

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10
Q

What is the commonest cause of rectal pain derived from urinary tract pathology?

A

Prostatitis

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11
Q

What are the causes of testicular pain derived from urinary tract pathology?

A
  • Acute orchitis
  • Acute epididymo-orchitis
  • Torsion of the testis
  • Varicocele
  • Haematocele
  • Hydrocele
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12
Q

What are the causes of urinary incontinence derived from urinary tract pathology?

A
  • UTI
  • Detrusor instability
  • Prostatic hypertrophy
  • Interstitial cystitis
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13
Q

What are the causes of urinary retention derived from urinary tract pathology?

A
  • Prostatic hypertrophy
  • Bladder neck obstruction
  • Urethral calculus
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14
Q

What are the differential causes for urinary tract symptoms from first principles?

A
  • Trauma
  • ‘Swelling’
    • ​Non-neoplastic
    • Benign
    • Malignant
      • Primary
      • Secondary
  • ‘Chronic’
    • ​Chronic inflammatory
  • ‘Acute’
    • ​Infection
    • Acute toxic
    • Immunological
  • ‘Stone’
    • ​Genetic
    • Metabolic
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15
Q

What do the kidneys do?

Think about each of these functions and work backwards from first principles to find the pathology.

A
  • Fluid and electrolyte balance
  • Resorption of solutes
  • Excretion
    • E.g. of conjugated xenobiotics
  • Endocrine
    • Renin - look at BP
    • Erythropoietin - look at RBCs
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16
Q

Who is most commonly affected by cystic disease of the kidney?

What can this present with and why?

A
  • Cystic disease is almost certainly in adults.
  • It can mean that instead of weighing 4-500g, a kidney can weigh 5-10kgs.
  • Simply because of its size it can present with pain.
  • Because the cysts bleed it can present with haematuria.
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17
Q

Describe the pathophysiology of nephrotic syndrome.

A
  • Proteinuria
    • ​>3.5g in 24 hours
    • ++++ Protein
    • Urine looks frothy
  • Hypoalbuminaemia
    • ​Serum albumin ≤30g/L
    • Albumin is lost in the urine
    • Gaps in podocytes allow proteins to leak into the urine
  • Oedema
    • Hypoalbuminaemia results in decreased intravascular oncotic pressure.
    • As a result, fluid moves out of the intravascular compartment and into the surrounding tissues causing oedema.
  • Hyperlipidaemia
    • ​Due to hypoalbuminaemia, the liver compensates and increased production of lipids.
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18
Q

Describe the pathophysiology of nephritic syndrome.

A
  • Haematuria
    • ​+++ Blood - microscopic or macroscopic haematuria.
    • Red cell casts - distinguishing feature, form in nephrons and indicate glomerular damage.
    • Haematuria occurs due to podocytes developing large pores which allows blood and protein to escape into the urine.
  • Proteinuria
    • ​++ Protein (small amount; less that nephrotic syndrome)
  • Hypertension
    • ​Usually only mild
  • Low urine volume (oliguria)
    • ​<300mL / day
    • Due to reduced renal function
  • Pain
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19
Q

What is hydronephrosis?

A

The kidney balloons up because of back pressure of urine when urinary outflow is obstructed.

This is a post-renal cause of kidney failure.

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20
Q

How do urinary calculi present?

What are its consequences?

A
  • Presents clinically. Can be acute or chronic.
  • Symptoms:
    • Renal colic (extreme pain)
    • Haematuria
  • Consequences:
    • Pyelonephritis
    • Obstructive uropathy
    • Hydronephrosis
    • Post-renal renal failure
21
Q

What are renal calculi made of?

Why do they form?

A
  • Calcium - 75%
    • Ca2+ very opaque - stones can be seen on plain film XR
    • ​Due to hypercalcaemia
      • Sarcoid
      • Renal tubular acidosis
      • Hyper parathyroidism
  • Uric acid - 20%+
    • ​Gout
  • Infection - proteus species
    • ​Obstruction (e.g. vesicoureteric reflux)
      • Infection is not so much the cause of stone but stones can form around it, particularly proteus stones.
  • Cystine - 1%
    • ​Genetic
    • Dehydration
22
Q

What are the 4 types of bladder disease?

A
  • Inflammation
    • Can be acute or chronic.
    • Many neutrophils and some dilated blood vessels infiltrating into bladder mucosa - likely to be acute cystitis (most often caused by infection).
  • Infection
  • Calculi
    • Can form in the bladder and cause damage to the mucosa (and therefore cause secondary infection) or haematuria.
  • Neoplasia
    • Formation of tumours.
23
Q

What are the immediate symptoms of bladder pathology?

A
  • Dysuria
  • Frequency
  • Haematuria
  • Proteinuria
  • Acute cystitis will present with acute pain.
24
Q

What are the common neoplasms of the urinary tract?

A
  • Prostate
    • ​Adenocarcinoma
  • Bladder
    • ​Urothelial (transitional cell) carcinoma
  • Renal
    • ​4/5 are clear cell carcinoma (ccRCC)
25
Q

What are the less common or rare urinary tract tumours?

A
  • Renal carcinomas other than clear cell including transitional cell carcinoma
  • Renal nephroblastoma (Wilms’ tumour)
  • Ureter transitional cell carcinoma
  • Renal / bladder sarcoma
26
Q

Describe Wilms’ Tumour.

A
  • Children (usually <3y)
  • Caused by th WT1 tumour suppressor gene
  • Histology resembles immature or embryological blastema
  • Younger patients have better prognosis
  • Surgery, radiotherapy and chemotherapy leads to ~90% survival
  • Asymptomatic abdominal mass
27
Q

Where does renal cell carcinoma originate?

What are the different types?

What are the risk factors?

A
  • Originates in the ducts, especially the proximal convoluted tubule.
  • Commonest type is clear cell carcinoma.
  • Other types:
    • Papillary renal cell carcinoma
    • Chromophobe renal cell carcinoma
  • Risk factors (incidence is increasing):
    • Smoking
    • Obesity
  • Genetic factors increasing risk:
    • von Hippel-Lindau Syndrome
    • autosomal dominant RCC
    • hereditary papillary RCC
28
Q

Describe how RCC grows.

A
  • Grows along the renal vein to the IVC.
  • Metastasises to the lung - ‘cannonball lesions’.
  • Tumour can grow along the renal vein into the IVC and grow up to the heart, or can metastasise in the blood and be trapped so forming metastases In the liver.
  • Important in the management of the disease. Many carcinomas spread through lymphatics into nodes but renal cancer very early spreads into the blood and therefore can end up in the lung or bones.
29
Q

How does RCC present?

A
  • Men > women
  • Haematuria +/- pain is the most common presentation.
  • Mass
  • Pain
  • Metastases
  • Paraneoplastic syndromes
    • Pyrexia
    • Hormones (e.g. EPO)
  • May be an incidental finding on a CXR - cannonball lesions.
30
Q

Describe bladder cancer.

A
  • Classic type is papillary.
  • Not just a single tumour – a change that happens across the entire mucosa because most of the carcinogens (e.g. from cigarettes) are concentrated in the urine.
  • So, the whole epithelium is exposed and therefore at risk.
  • Spectrum of malignancy from superficial, carcinoma in situ to deeply invasive.
  • Tend to recur - 5% pa.
  • Requires careful monitoring and follow-up.
31
Q

What are the presenting symptoms of bladder cancer?

A
  • Haematuria - even once is significant.
  • Dysuria
  • Obstruction
32
Q

What are the causes and effects of acute renal failure?

A
  • Pre-renal
    • ​Shock
    • Major Trauma
  • Renal
    • ​Some glomerulonephritides
    • Toxic (e.g. drugs)
    • Malignant hypertension
    • Vasculitis
    • Analgesics
  • Post-renal
    • ​Obstruction
  • Effects:
    • ​High potassium
    • High creatinine
    • May be oliguria
    • Hypertension
    • Lipids in nephrotic syndrome
33
Q

What are the causes and effects of chronic renal failure?

A
  • Pre-renal
    • ​Atherosclerosis
  • Renal
    • ​Glomerulonephritis
    • DM
    • Hypertension
    • Polycystic kidneys
  • Post-renal
    • ​Obstruction
  • Effects
    • ​High potassium
    • High creatinine
    • May be oliguria
    • Hypertension
    • Anaemia
    • Small kidneys
34
Q

What are the clinical features of obstructive uropathy?

A
  • Anaemia
  • Immunosuppression
  • Bone disease
  • Neuropathy
  • Neoplasia
35
Q

What are the causes of bladder outflow obstruction?

A
  • Prostate enlargement in men
  • Uterine prolapse in women
  • Calculi
  • Tumours
  • Urethral strictures
  • Neurological damage
36
Q

What happens to the mucosa of the bladder as a result of bladder outflow obstruction?

A

Mucosa becomes folded and rugous because the muscle underlying is thickened because the bladder has been attempting to push urine out through a narrow area constricted because of prostatic enlargement.

As a result, the bladder may have dilated but the muscular layers have hypertrophied so when the bladder shrinks it causes folds.

37
Q

What are the causes of post-renal renal failure?

A
  • Hydronephrosis / hydroureter
  • Caused by obstruction
    • Extrinsic
      • ​Tumours (e.g. cervical cancer)
    • Intrinsic
      • ​Within the wall - intrinsic tumour e.g. transitional cell carcinoma.
      • In the lumen - calculi, blood clot.
  • Must be bilateral to cause renal failure (or unilateral if the patient only has one kidney).
38
Q

What are the common diseases of the prostate?

A
  • BPH
  • Carcinoma
  • Prostatitis
  • Prostate disease increases with age.
39
Q

Describe benign nodular hyperplasia of the prostate.

A
  • Non-neoplastic - associated with hormonal imbalance.
  • Nodular hyperplasia of glands and stroma.
  • Not premalignant.
  • Associated with infection.
  • Treatable
    • Treatment can be hormonal or surgical.
  • Involves the transitional zone of the prostate, plus peri-urethral glands.
  • Compresses and elongates the urethra.
  • Involvement of peri-urethral zone interferes with urethral sphincter.
  • Causes urinary retention:
    • Acute retention - painful
    • Chronic retention - painless and more gradual
40
Q

How does BPH present?

A
  • With chronic urinary retention, there may be complaints of:
    • Dribbling
    • esitancy
    • Urgency
    • Slow flow
    • Rarely haematuria
  • Can present with a HUGE bladder - up to umbilicus.
41
Q

What are the complications of BPH?

A
42
Q

Compare BPH to prostate carcinoma.

A
43
Q

Describe the pathological features of prostate carcinoma.

A
  • Prostatic intraepithelial neoplasia - precursor.
  • Adenocarcinoma usually >50 years.
    • Occurs in posterior subcapsular area
    • Asymmetric firm enlargement
    • Metastasises (especially to bone)
  • Latent or indolent (incidental) carcinoma.
    • Microscopic incidental focus
    • Common - incidence is high in old age
    • Lesions dormant; metastses in 30% after 10 years
44
Q

Describe the spread and clinical features of prostate carcinoma.

A
  • Stage TN
    • Direct
    • Via lymphatics
    • Via blood
  • Presents with:
    • Urinary symptoms
    • Incidental finding on rectal examination
    • Bone metastases
    • Lymph node metastases
  • Gleason score for differentiation and distribution
45
Q

What is the difference between in situ, indolent and aggressive prostate carcinoma?

A
  • In situ - it is in the ducts but it is not going anywhere.
  • Indolent - yes, it is invasive. But, it is not going to kill the patient.
  • Aggressive - going to kill the patient.
46
Q

What is the common site of bony mets from prostate cancer?

A

​The vertebrae

Picture: adenocarcinoma sclerotic bone metastases.

47
Q

How is prostate carcinoma diagnosed?

A
  • Imaging:
    • USS
    • X-ray
    • Isotope bone scan
  • Cytoscopy
    • ?cytology
  • Biochemistry
    • PSA
  • Haematological
    • Bone marrow involvement
  • Biopsy
    • ?cytology
48
Q

What are the treatment options for prostate carcinoma?

A
  • Oestrogenic
  • GnRH analogues
  • Orchidectomy
  • Radiotherapy
  • Radical prostatectomy

Elderly Years (28 decks)

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