Presentation of Diseases of Kidney and Urinary Tract Flashcards
What does the upper urinary tract include?
Kidneys - parenchyma and pelvi-calyceal system
Ureters - pelvi-ureteric junction, ureter and vesico-ureteric junction
What does the lower urinary tract include?
Bladder
Bladder outflow tract - bladder neck, prostate, external urethral sphincter, urethra, urinary meatus, and foreskin
What is the nature of renal diseases?
Infection, inflammation, iatrogenic (nephrotoxicity, PCNL), neoplasia (renal tumours and collecting system tumours), trauma, vascular and hereditary
What is infection in renal diseases called?
Pyelonephritis
What are types of inflammation in renal diseases?
Glomerulonephritis and tubulointestinal nephritis
What are vascular causes of renal disease?
Atherosclerosis, hypertension and diabetes
What are hereditary causes of renal disease?
Polycystic kidney disease and nephrotic syndrome
What is included in the presentation of renal diseases?
pain, pyrexia, haematuria, proteinuria, pyuria (pus in urine due to infection), mass on palpation and renal failure
What is the definition of proteinuria?
Urinary protein excretion of more than 150mg/day
In clinical practice, how many types of haematuria is there?
3 - visible (Frank), microscopic and dipstick
What is the definition of microscopic haematuria?
More than 3 red blood cells per high power field
What is oliguria?
When urine output is more than 0.5ml/kg/hour
What is anuria?
Absolute anuria - no urinary output
Relative anuria - less than 100ml/24hrs
What is polyuria?
Urine output more than 3l/day
What is nocturia?
Waking up at night equal to or more than 1 occasion in the night
What is nocturnal polyuria?
Nocturnal urine output more than 1/3 of total urine output in 24hrs
What is the definition of acute kidney injury in terms of staging?
Risk - increase in creatinine level x 1.5 or decrease in GFR by 25%
Injury - 2x and 50%
Failure - 3x and 75%
Loss - persistent AFR or complete loss of kidney function > 4 weeks
End stage kidney disease - complete loss of function more than 3 months
What are the functions of the kidney?
Body fluid homeostasis - fluid overload
Electrolyte homeostasis - Na, K and Cl
Acid base homeostasis
Regulation of vascular tone - BP
Excretory functions - physiological waste and drugs
Endocrine functions - erythropreitin, Vit D and renin
What are some of the presentations of chronic renal failure?
Asymptomatic, tiredness, anaemia, oedema, high BP, bone pain, pruritus, N/V, dyspnoea, pericarditis, neuropathy and coma
What is the nature of ureteric diseases?
Infection - ureteritis
Iatrogenic/ Trauma - cut or tied in hysterectomy or colon resection Neoplasia
Hereditary - PUJ obstruction and VUJ reflux
Obstruction
What are some types of neoplasia in ureteric diseases?
TCC of ureter, TCC of bladder obstructing VUJ, prostate cancer obstructing VUJ, pelvic malignancy, pelvic or para-aortic lymphadenopathy
What are the types of obstruction in ureteric diseases?
Intra-luminal - stone or blood clot
Intra-mural - scar tissue and TCC
Extra-luminal - pelvic mass and lymph nodes
What is the presentation of ureteric diseases?
Pain, pyrexia, haematuria, palpable mass, and renal failure is bilateral obstruction or single functioning kidney
What is the nature of bladder diseases?
Infection - cystitis
Inflammation - interstitial cystitis and colo-vesical fistula
Iatrogenic
Neoplasia
Idiopathic - overreactive bladder syndrome
Degenerative - chronic urinary retention
Neurological - bladder dysfunction
What iatrogenic/ trauma can cause bladder diseases?
Bladder rupture
Bladder injury from hysterectomy resulting in vesico-vaginal fistula
What are the types of bladder neoplasia?
TCC of bladder making 90%
9% small cell carcinoma
1% adenocarcinoma
What is the presentation of bladder diseases?
Pain (suprapubic region), pyrexia, haematuria, recurrent UTIs, chronic urinary retention, urinary leak from vagina and pneumaturia
Lower urinary tract symptoms (LUTS)
What is included in lower urinary tract symptoms?
Storage LUTS (function) - frequency, nocturia, urgency, and urge incontinence
Voiding LUTS (obstruction) - poor flow, intermittency, and terminal dribbling
Incontinence
What is the risk of bladder cancer in a patient with visible haematuria?
25-30%
What is the risk of renal cancer in patient with frank haematuria?
0.5-1%
What can cause lower urinary tract symptoms (LUTS)?
Bladder pathology - OAB, UTI, interstitial cystitis and bladder cancer
Bladder outflow obstruction
Pelvic floor dysfunction
Neurological causes
Systemic disorders
What neurological disorders can cause LUTS?
Supra-pontine lesions - stroke, Alzheimer’s, and Parkinson’s
Infra-pontine supra-sacral lesions - spinal cord injury, disc prolapse and spina bifida
Infra-sacral - MS, diabetes, cauda equina compression and surgery
Describe the control of micturition?
Cortical centre - bladder sensation and inhibition of micturition
Pons
Sacral segments - S2-4 micturition reflex
Micturition cycle - storage and voiding phase
What is the nature of bladder outflow tract diseases?
Infection/ Inflammation - prostatitis and balanitis
Iatrogenic/ Trauma - pelvic floor damage or urethral injury from catheterisation
Neoplasia - prostate and penile
Idiopathic - chronic pelvic pain syndrome
Obstruction
What can cause obstruction of bladder outflow tract?
Primary bladder neck obstruction, benign prostate enlargement, urethral stricture, meatal stenosis and phimosis
What is the presentation of bladder outflow tract diseases?
Pain, (suprapubic or perineal), pyrexia, haematuria, LUTS, recurrent UTIs, acute urinary retention and chronic urinary retention
What is the definition of acute urinary retention?
Painful inability to void with a palpable and percussible bladder
Residuals vary from 500ml to 1l
Main factor is benign prostatic obstruction (BPO)
What is the initial treatment for acute urinary retention?
Catheterisation
Treat underlying trigger if present
What is the definition of chronic urinary retention?
Painless, palpable, and percussible bladder after voiding
Often able to void but residual of 400mls to 2l
Main factor is detrusor muscle underactivity
Presents as LUTS or complications
When does chronic urinary retention need treatment?
Asymptomatic with low residuals don’t necessarily need treatment
Patients with symptoms or complications need treatment
What is the treatment for chronic urinary retention?
Catheterisation
If high pressure then physiological or pathological diuresis occurs
Long term urethral or suprapubic catheter, CISC, and TURP if benign prostatic obstruction
What are some complications of chronic urinary retention?
UTI, post-decompression haematuria, pathological diuresis, electrolyte abnormalities, and persistent renal dysfunction
Describe UTIs
Infection of urinary tract
Diagnosis of microbiological evidence and symptoms or signs
Two types - compilated (need investigated) and uncomplicated (young sexually active female)
How is a diagnosis of a UTI made?
Diagnosis of microbiological evidence and symptoms or signs - bacterial count of 104 from MSSu culture
At least one - fever, loin/ flank pain, tenderness, subrapubic pin, urinary frequency, urinary urgency, and dysuria
What are some factors to consider when differentiating between complicated and uncomplicated UTIs?
Age, sexual activity, gender, co-morbidities, abnormal renal tract, foreign body and type of organism
What are some complications of UTIs?
Infection (sepsis), renal failure, bladder malignancy, acute renal retention, frank haematuria, bladder or renal stones
What are the investigations for UTIs?
MSSU
Lower tract - flow studies, residual bladder scan and cystoscopy
Upper tract - USS kidneys,, IVU, MAg-3, DMSA scan
What is the treatment for UTIs?
Appropriate antibiotic therapy
Treat complications and cause
What are some emergencies related to UTIs?
Acute renal failure, sepsis, renal colic, severe haematuria causing haemorrhagic shock, metastatic disease, acute urinary retention, chronic high pressure urinary retention, testicular torsion and paraphimosis
Which organisms are associated with UTIs?
E.coli
Klebsiella species
Proteus species
Pseudomonas aeruginosa
