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renal system > Presentation of Diseases > Flashcards

Presentation of Diseases Flashcards

1
Q

What does the upper urinary tract consist of?

A

Kidneys

  • Parenchyma
  • Pelvi-calyceal system

Ureters

  • Pelvi-ureteric junction
  • Ureter
  • Vesico-ureteric junction
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2
Q

What does the lower urinary tract consist of?

A

Bladder

Bladder outflow tract

  • Bladder neck (intrinsic urethral sphincter)
  • Prostate
  • External urethral sphincter/pelvic floor
  • Urethra
  • Urethral meatus
  • Foreskin
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3
Q

What can be the nature of renal disease?

A
  • Infection
  • Inflammation
  • Iatrogenic
  • Neoplasia
  • Trauma
  • Vascular
  • Hereditary
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4
Q

Give an example of a renal infection.

A

Pyelonephritis

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5
Q

Give examples of renal inflammation.

A
  • Glomerulonephritis

- Tubulinterstitial nephritis

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6
Q

What iatrogenic renal disease is there?

A
  • Nephrotoxicity

- PCNL

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7
Q

What neoplastic renal conditions are there?

A
  • Renal tumour

- Collecting system tumours

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8
Q

What trauma can cause renal disease?

A

Blunt trauma

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9
Q

What vascular renal disease is there?

A
  • Atherosclerosis
  • Hypertension
  • Diabetes
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10
Q

What hereditary renal disease is there?

A
  • Polycystic kidney disease

- Nephrotic syndrome

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11
Q

How does renal disease present?

A
  • Pain
  • Pyrexia
  • Haematuria (blood in the urine)
  • Proteinuria (protein in the urine)
  • Pyuria (pus in the urine)
  • Mass on palpation
  • Renal failure
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12
Q

What is the definition of proteinuria?

A

Urinary protein excretion > 150mg/day

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13
Q

How many types of haematuria is there?

A

3

  • Microscopic
  • Dipstick
  • Visible
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14
Q

What is the definition of microscopic haematuria?

A

≥3 red blood cells per high power field

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15
Q

Oliguria

A

Urine output <0.5ml/kg/hour

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16
Q

Anuria

A
  • Absolute anuria - No urine output;

- Relative anuria - <100ml/24 hours

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17
Q

Polyuria

A

Urine output >3L/24 hours

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18
Q

Nocturia

A

Waking up at night ≥1 occasion to micturate

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19
Q

Nocturnal polyuria

A

Nocturnal urine output >1/3 of total urine output in 24 hours

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20
Q

What is another term for acute renal failure?

A

Acute kidney injury

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21
Q

How is AKI defined?

A

RIFLE

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22
Q

What does R stand for in RIFLE?

A 
Risk 
-Increase in serum creatinine level (1.5x)
or 
-Decrease in GFR by 25%, 
or 
-UO <0.5 mL/kg/h for 6 hours
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23
Q

What does I stand for in RIFLE?

A 
Injury 
-Increase in serum creatinine level (2.0x)
or 
-Decrease in GFR by 50%, 
or 
-UO <0.5 mL/kg/h for 12 hours
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24
Q

What does F stand for in RIFLE?

A 
Failure  
-Increase in serum creatinine level (3.0x),
or 
-Decrease in GFR by 75%, or serum creatinine level >355μmol/L with acute increase of >44μmol/L;
or 
-UO <0.3 mL/kg/h for 24 hours, 
or 
-Anuria for 12 hours
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25
Q

What does L stand for in RIFLE?

A

Loss

-Persistent ARF or complete loss of kidney function >4 weeks

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26
Q

What does E stand for in RIFLE?

A

End-stage kidney disease

-Complete loss of kidney function >3 months

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27
Q

What are the functions of the kidneys?

A
  • Body fluid homeostasis
  • Electrolyte homeostasis
  • Acid-base homeostasis
  • Regulation of vascular tone
  • Excretory functions
  • Endocrine functions
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28
Q

What role do the kidneys play in acid-base homeostasis?

A
  • Excrete H

- Generate HCO3

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29
Q

How does chronic renal failure present? (early stages)

A
  • Asymptomatic (found on blood and urine testing)
  • Tiredness
  • Anaemia
  • Oedema
  • High blood pressure
  • Bone pain due to renal bone disease
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30
Q

How does chronic renal failure present? (advanced stages)

A
  • Pruritus
  • Nausea/vomiting
  • Dyspnoea -Pericarditis -Neuropathy
  • Coma
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31
Q

What can be the nature of ureteric diseases?

A
  • Infection
  • Iatrogenic/trauma
  • Neoplasia
  • Hereditary
  • Obstruction
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32
Q

Give an example of a ureteric infection.

A

Ureteritis

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33
Q

Give examples of iatrogenic/trauma ureteric disease.

A

Inadvertently cut or tied during hysterectomy or colon resection

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34
Q

Give examples of neoplastic ureteric disease

A
  • TCC of ureter
  • TCC of bladder obstructing VUJ
  • Prostate cancer obstructing VUJ
  • Pelvic malignancy
  • Pelvic or para-aortic lymphadenoapathy
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35
Q

Give examples of hereditary ureteric disease

A
  • PUJ obstruction

- VUJ reflux

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36
Q

Give examples of obstruction causing ureteric disease

A
  • Intra-luminal ( stone, blood clot)
  • Intra-mural (scar tissue, TCC)
  • Extra-luminal (pelvic mass, lymph nodes)
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37
Q

How can ureteric disease present?

A
  • Pain (eg. renal colic)
  • Pyrexia
  • Haematuria
  • Palpable mass (ie. hydronephrosis)
  • Renal failure (only if bilateral obstruction or single functioning kidney)
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38
Q

What can be the nature of bladder disease?

A
  • Infection
  • Inflammation
  • Iatrogenic/trauma
  • Neoplasia
  • Idiopathic
  • Degenerative
  • Neurological
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39
Q

Give an example of a bladder infection.

40
Q

Give examples of inflammatory bladder disease

A
  • Interstitial cystitis

- Colonic diverticulitis resulting in colo-vesicle fistula

41
Q

Give examples of iatrogenic/trauma bladder diseases

A
  • Bladder rupture

- Bladder injury from hysterectomy (resulting in vesico-vaginal fistula)

42
Q

Give examples of neoplastic bladder diseases

A
  • TCC of bladder

- Squamous cell carcinoma of bladder

43
Q

Give an examples of a degenerative bladder disease

A

Chronic urinary retention

44
Q

Give an example of a neurological bladder disease

A

Neurogenic bladder dysfunction

45
Q

How can bladder disease present?

A
  • Pain (suprapubic)
  • Pyrexia
  • Haematuria
  • Lower urinary tract symptoms (LUTS)
  • Recurrent UTIs
  • Chronic urinary retention (due to bladder underactivity)
  • Urinary leak from vagina (i.e. vesico-vaginal fistula)
  • Pneumaturia (i.e. colo-vesical fistula)
46
Q

What are storage LUTS?

A
  • Frequency
  • Nocturia
  • Urgency
  • Urge incontinence
47
Q

What are voiding LUTS?

A
  • Poor flow
  • Intermittency
  • Terminal dribbling
48
Q

What are incontinence LUTS?

A
  • Stress
  • Urge
  • Mixed
  • Overflow
  • Neurogenic
  • Dribbling
49
Q

What is the risk of bladder cancer in a patient who presents with frank haematuria?

50
Q

What is the risk of renal cancer in a patient who presents with frank haematuria?

51
Q

What can cause LUTS?

A
  • Bladder pathology
  • Bladder outflow obstruction
  • Pelvic floor dysfunction
  • Neurological causes
  • Systemic disorders
52
Q

What type of neurological lesions can cause LUTS?

A
  • 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 (e.g. multiple sclerosis, diabetes, cauda equina compression, surgery to retroperitoneum)
53
Q

What systemic disorders can cause LUTS?

A
  • Chronic renal failure
  • Cardiac failure
  • Diabetes mellitus
  • Diabetes insipidus
54
Q

What bladder pathology can cause LUTS?

A
  • OAB
  • UTI
  • Interstitial cystitis
  • Bladder cancer
55
Q

What is the micturition cycle?

A
  • Storage (or filling) phase

- Voiding phase

56
Q

What role does the cortical centre play in the control of micturition?

A

Bladder sensation and conscious inhibition of micturition

57
Q

What role does the pons play in the control of micturition?

A

Micturition centre

58
Q

What role do the sacral segments S2-S4 play in the control of micturition?

A

Micturition reflex

  • Relaxation of internal urethral sphincter (autonomic - sympathetic)
  • Relaxation of external urethral sphincter (somatic)
  • Contraction of detrusor muscle (autonomic – parasympathetic)
59
Q

What can be the nature of bladder outflow tract disease?

A
  • Infection/inflammation
  • Iatrogenic/trauma
  • Neoplasia
  • Idiopathic
  • Obstruction
60
Q

Give examples of infection/inflammatory bladder outflow tract diseases.

A
  • Prostatitis

- Balanitis

61
Q

Give examples of iatrogenic/trauma bladder outflow tract disease.

A
  • Pelvic floor damage after traumatic vaginal delivery or hysterectomy
  • Urethral injury from catheterisation or pelvic fracture
62
Q

Give examples of neoplastic bladder outflow tract disease

A
  • Prostate cancer

- Penile cancer

63
Q

Give an example of idiopathic bladder outflow tract disease.

A

Chronic pelvic pain syndrome

64
Q

Give examples of obstructive bladder outflow tract disease

A
  • Primary bladder neck obstruction
  • Benign prostatic enlargement (BPE) causing obstruction
  • Urethral structure
  • Meatal stenosis
  • Phimosis
65
Q

How can bladder outflow tract disease present?

A
  • Pain (suprapubic or perineal)
  • Pyrexia
  • Haematuria
  • Lower urinary tract symptoms (LUTS)
  • Recurrent UTIs
  • Acute urinary retention
  • Chronic urinary retention
66
Q

How is acute urinary retention defined?

A

Painful inability to void with a palpable and percussible bladder

67
Q

How can residual volumes vary in acute urinary retention?

A

Residuals vary from 500ml to >1 litre depending on time lag in seeking medical attention

68
Q

What are the risk factors for acute urinary retention?

A
  • Main risk factor is BPO
  • UTI
  • Urethral stricture
  • Alcohol excess
  • Post-operative causes
  • Acute surgical or medical problems
69
Q

How can acute urinary retention occur for those with BPO?

A

For those with BPO, can occur spontaneously (i.e. natural progression of BPO) or triggered by an unrelated event (eg. constipation, alcohol excess, post-operative causes, urological procedure)

70
Q

What is the immediate treatment for acute urinary retention?

A

Catheterisation (either urethral or suprapubic)

71
Q

What are the possible complications of acute urinary retention?

A
  • UTI
  • Post-decompression haematuria
  • Pathological diuresis
  • Renal failure
  • Electrolyte abnormalities
72
Q

How should acute urinary retention be treated if it is due to BPE but there is no renal failure?

A

If due to BPE and no renal failure, start alpha blocker immediately and remove catheter in 2 days (60% will void successfully); if fail to void, recatheterise and organise TURP (after 6 weeks)

73
Q

How is chronic urinary retention defined?

A

Painless palpable and percussible bladder after voiding

74
Q

How can residual volumes vary in chronic urinary retention?

A

Patients often able to void but with residuals ranging from 400ml to >2 litres depending on stage of condition (i.e. wide spectrum)

75
Q

What is the main aetiological factor in chronic urinary retention?

A

Main aetiological factor is detrusor underactivity which can be primary (i.e. primary bladder failure) or secondary (i.e. due to longstanding BOO, such as BPO or urethral stricture)

76
Q

How does chronic urinary retention present?

A

Presents as LUTS or complications (e.g. UTI, bladder stones, overflow incontinence, post-renal or obstructive renal failure) or incidental finding

77
Q

When do overflow incontinence and renal failure occur in chronic urinary retention?

A

Overflow incontinence and renal failure occur at severe end of spectrum, when bladder capacity is reached and bladder pressure is in excess of 25cm water (i.e. decompensated chronic urinary retention or acute-on-chronic urinary retention or chronic high-pressure urinary retention)

78
Q

Who does not necessarily need treated for chronic urinary retention?

A

Asymptomatic patients with low residuals do not necessarily need treatment

79
Q

Who needs to be treated for chronic urinary retention?

A

Patients with symptoms or complications

80
Q

What is the immediate treatment for chronic urinary retention?

A

Immediate treatment is catheterisation (either urethral or suprapubic initially, followed by CISC if appropriate)

81
Q

What are the possible complications of chronic urinary retention?

A
  • UTI
  • Post-decompression haematuria
  • Pathological diuresis
  • Electrolyte abnormalities (hyponatraemia, hyperkalaemia, metabolic acidosis)
  • Persistent renal dysfunction due to acute tubular necorsis
82
Q

What pathological diuresis features are present in chronic urinary retention?

A 
-Urine output > 200 ml/hr
\+
-Postural hypotension (systolic differential >20mmHg between lying and standing) 
\+
-Weight loss
\+
-Electrolyte abnormalities
83
Q

How should chronic urinary retention be managed?

A
  • Manage with iv fluids (total input = 90% of output) and monitor closely; liaise with renal team
  • Subsequent treatment is with either long term urethral or suprapubic catheter, CISC or TURP if due to BPE
84
Q

How does the successfulness of TURP differ between types of urinary retention?

A
  • TURP in chronic retention has a less successful outcome than for acute retention
  • Patients with high pressure chronic retention has better outcome with TURP than patients with low pressure chronic retention
85
Q

How is UTI defined?

A

Defined as infection affecting urinary tract (including kidneys, bladder, prostate, testis and epididymis)

86
Q

What does diagnosis of a UTI require?

A

A diagnosis requires microbiological evidence AND symptoms/signs:

  • Microbiological evidence: Bacterial count of 104 cfu/ml from MSSU specimen with no more than two species of micro-organisms
  • Symptoms/signs: At least one of the following: Fever >38ºC; loin/flank pain or tenderness; suprapubic pain or tenderness; urinary frequency; urinary urgency; dysuria
87
Q

What are the 2 types of UTI?

A
  • Uncomplicated UTIs (young sexually active females only with clear relation to sexual activity)
  • Complicated UTIs (everyone else!)
88
Q

What type of UTI always needs to be investigated?

A

Complicated UTI

89
Q

What factors should be considered when differentiating between complicated and uncomplicated UTI?

A
  • Age
  • Sexual activity (females)
  • Gender
  • Co-morbidities (e.g. immunosuppression, renal failure, medications)
  • Abnormal renal tract (e.g. stones, renal outflow obstruction, BOO, horseshoe kidney, VU reflux, renal scarring, bladder tumour)
  • Foreign body (e.g. catheter, ureteric stent)
  • Type of organisms (E. coli, Staph. saprophyticus, Klebsiella, Proteus, Pseudomonas, Staph aureus)
90
Q

What does presentation of UTI depend on?

A

Organ affected

  • Bladder: cystitis
  • Prostate: prostatitis
  • Kidney: pyelonephritis
  • Testis: orchitis
91
Q

How is recurrent UTI defined?

A

Defined as > 3 UTIs per year (or >2 in 6 months)

92
Q

How is relapsed UTI defined?

A

Defined as UTI by same organisms within 2 weeks of preceding UTI (usually indicative of inadequately treated UTI e.g. wrong antibiotic, dose or duration)

93
Q

What are the possible complications of UTI?

A
  • Infective: sepsis (esp. pyelonephritis), perinephric abscess
  • Renal failure (scarring)
  • Bladder malignancy (squamous cell carcinoma)
  • Acute urinary retention
  • Frank haematuria
  • Bladder or renal stones
94
Q

What investigations should be carried out for UTI?

A
  • MSSU/CSU
  • Lower tract: flow studies, residual bladder scan, cystoscopy
  • Upper tract: USS kidneys, IVU/CT-KUB, MAG-3 renogram, DMSA scan
95
Q

How should UTIs be treated?

A
  • Appropriate antibiotic therapy (type? duration? route?)

- Treat complications and cause

96
Q

What emergencies related to urinary tract disease are there?

A
  • Acute renal failure
  • Sepsis due to UTI +/- upper or lower urinary tract obstruction
  • Renal colic
  • Severe haematuria causing haemorrhagic shock
  • Metastatic disease causing metabolic derangements (eg. hypercalcaemia from bony metastases), spinal cord compression from vertebral metastases, etc.
  • Acute urinary retention
  • Chronic high-pressure urinary retention
  • Iatrogenic injury/Trauma to upper or lower urinary tracts, penis and testis
  • Testicular torsion
  • Paraphimosis
  • Priapism
97
Q

Give examples of organisms commonly associated with UTIs.

A
  • E coli
  • Klebsiella species
  • Proteus species
  • Pseudomonas aeruginosa

renal system (26 decks)

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