Presentation of Diseases of the Kidney and Urinary tract Flashcards
what comprises the upper urinary tract
- kidneys - parenchyma, pelvi-calyceal system
2. ureters - PUJ, ureter, VUJ
what comprises the lower urinary tract
- bladder
- bladder outflow tract
- bladder neck (intrinsic urethral sphincter)
- prostate
- external urethral sphincter/pelvic floor
- urethra
- urethral meatus
- foreskin
what are the 7 different types of renal/kidney diseases
- infection
- inflammation
- iatrogenic
- neoplasia
- trauma
- vascular
- hereditary
for each of the 7 types of kidney disease, give an example
- 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
how can renal disease present
pain, pyrexia, haematuria, proteinuria, pyuria, mass on palpation, renal failure
what is the definition of proteinuria
urinary protein excretion of >150mg/day
how many types of haematuria are there
2 - microscopic and macroscopic
what is the definition of microscopic haematuria
≥3 red blood cells per high power field
define oliguria
urine output <0.5ml/kg/hour
ie abnormally low urine output
define anuria
Absolute anuria - No urine output
Relative anuria - <100ml/24 hours
define polyuria
urine output >3L/24 hours (i.e. abnormally large urine output)
define nocturia
Waking up at night ≥1 occasion to micturate
define nocturnal polyuria
Nocturnal urine output >1/3 of total urine output in 24 hours
for acute kidney injury (AKI) what are the definitions in terms of staging
use RIFLE staging criteria
R - risk I - injury F - failure L - loss E - end stage kidney disease
explain the R stage from RIFLE
Risk - at risk of acute kidney injury when:
increase in serum creatinine level (1.5x)
OR
decrease in GFR by 25%
OR
UO <0.5mL/kg/h for 6 hours
explain the I stage from RIFLE
Injury - kidneys injured when: increase in serum creatinine level (2.0x) OR decease in GFR by 50% OR UO <0.5 mL/kg/h for 12 hours
explain the F stage from RIFLE
Failure - kidneys go into failure when:
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
explain the L stage from RIFLE
Loss - Persistent ARF or complete loss of kidney function >4 weeks
explain the E stage from RIFLE
End stage kidney disease - complete loss of kidney function >3 months
what are the functions of the kidney
- body fluid homeostasis (fluid overload - peripheral oedema, congestive cardiac failure, pulmonary oedema)
- electrolyte homeostasis (Na+, K+, Cl-, etc)
- acid base homeostasis (excrete H+, generate HCO3-)
- regulation of vascular tone (regulate BP)
- excretory functions (physiological waste esp urea, drugs)
- endocrine functions (erythropoeitin, VIt D metabolism, renin)
how can chronic renal failure present
Asymptomatic (found on blood and urine testing)
- tiredness
- anemia
- oedema
- high blood pressure
- bone pain due to renal bone disease
- Pruritus (in advanced renal failure)
- Nausea/vomiting (in advanced renal failure)
- Dyspnoea (in advanced renal failure)
- Pericarditis (in advanced renal failure)
- Neuropathy (in advanced renal failure)
- Coma (untreated advanced renal failure)
what are the 5 types of ureteric diseases
- infection
- iatrogenic/trauma
- neoplasia
- hereditary
- obstruction
for each of the 5 types of ureteric disease, give an example
- infection - ureteritis
- iatrogenic/trauma - inadvertently cut or tied during hysterectomy or colon resection
- neoplasia - TCC of ureter, TCC of bladder obstructing VUJ, prostate cancer obstructing VUJ, pelvic malignancy, pelvic or para-aortic lymphadenopathy
- hereditary - PUJ obstruction, VUJ reflux
- obstruction
- intra-luminal (stone, blood clot)
- intra-mural (scar tissue, TCC)
- extra-luminal (pelvic mass, lymph nodes)
how can ureteric disease present
pain (eg renal colic), pyrexia, haematuria, palpable mass (ie hydronephrosis), renal failure (only if bilateral obstruction or single functioning kidney)
what are the 7 types of bladder disease
- infection
- inflammation
- iatrogenic/trauma
- neoplasia
- idiopathic
- degenerative
- neurological
for each of the 7 types of bladder disease, give an example
- infection - cystitis
- inflammation - interstitial cystitis, colonic diverticulitis resulting in colo-vesical fistula
- iatrogenic/Trauma - bladder rupture, bladder injury from hysterectomy (resulting in vesico-vaginal fistula)
- neoplasia - TCC of bladder, squamous cell carcinoma of bladder
- idiopathic - overactive bladder syndrome
- degenerative - chronic urinary retention
- neurological - neurogenic bladder dysfunction
how can bladder diseases present
pain (suprapubic), pyrexia, haematuria, LUTS (storage and voiding symptoms), recurrent UTI, chronic urinary retention, urinary leak from vagina, pneumaturia
the bladder is called an “unreliable witness” due to LUTS having multiple causes - name these causes
- bladder pathology
- bladder outflow obstruction
- pelvic floor dysfunction
- neurological causes
- systemic disorders
what are the three area responsible for control of micturition
- cortical centre (bladder sensation and conscious inhibition of micturition)
- pons (micturition centre)
- sacral segments (S2-S4) (micturition reflex)
what comprises the micturition reflex
- relaxation of internal urethral sphincter (autonomic-sympathetic)
- relaxation of external urethral sphincter (somatic)
- contraction of detrusor muscle (autonomic-parasympathetic)
what are the two phases of the micturition cycle
- storage (filling) phase
2. voiding phase
what are the 5 types of bladder outflow tract diseases
- infection/inflammation
- iatrogenic/trauma
- neoplasia
- idiopathic
- obstruction
for each of the 5 types of bladder outflow tract diseases, give an example
- Infection/Inflammation - prostatitis, balanitis
- Iatrogenic/Trauma - pelvic floor damage after traumatic vaginal delivery or hysterectomy, urethral injury from catheterisation or pelvic fracture
- Neoplasia - prostate cancer, penile cancer
- Idiopathic - chronic pelvic pain syndrome
- Obstruction
- primary bladder neck obstruction
- benign prostatic enlargement (BPE) causing obstruction
- urethral stricture
- meatal stenosis
- phimosis
how do bladder outflow tract diseases present
Pain (suprapubic or perineal), Pyrexia, Haematuria, LUTS (voiding, overflow incontinence), Recurrent UTIs, Acute urinary retention, Chronic urinary retention
what is the definition of acute urinary retention
painful inability to void with a palpable and percussible bladder
what are the residuals for acute urinary retention
vary from 500ml to 1 litre (but usually <1 litre)
what are the main causes of acute urinary retention
main cause is BPO BUT can also occur independently of BPO (eg. UTI, urethral stricture, alcohol excess, post-operative causes, acute surgical or medical problems)
for patients with BPO, what usually triggers acute urinary retention
usually triggered by an unrelated event (eg. constipation, alcohol excess, post-operative causes, urological procedure)
what is the immediate treatment for acute urinary retention
catheterisation (either urethral or suprapubic)
BUT
Treat underlying trigger if present
what is the definition of chronic urinary retention
painless, palpable and percussible bladder after voiding
what are the residuals for patients with chronic urinary retention
patient often able to void BUT residuals range from 400ml to >2 litres depending on stage of condition (i.e. wide spectrum)
what is the main etiological factor for chronic urinary retention
detrusor underactivity:
- primary - ie primary bladder failure
- secondary - ie due to longstanding BOO, such as BPO or urethral stricture
how does chronic urinary retention present
LUTS or complications (e.g. UTI, bladder stones, overflow incontinence, post-renal or obstructive renal failure) or incidental finding
what happens at the severe end of the spectrum when bladder capacity is reached and bladder pressure is in excess of 25cm water (i.e. high pressure chronic)
overflow incontinence and renal failure
what patients with chronic urinary retention do not need treatment
asymptomatic patients with low residuals
what is the immediate treatment of chronic urinary retention
catheterisation (either urethral or suprapubic initially, followed by CISC if appropriate)
what are complications of chronic urinary retention
UTI, post-decompression haematuria, pathological diuresis, electrolyte abnormalities (hyponatraemia, hyperkalaemia, metabolic acidosis), persistent renal dysfunction due to acute tubular necrosis
what are the two types of diuresis that can occur in HIGH pressure chronic urinary retention
- Physiological (usually <200ml/hour)
- Pathological (usually >200ml/hour)
what is subsequent treatment for chronic urinary obstruction
either long term urethral or suprapubic catheter, CISC or TURP if due to benign prostatic obstruction (BPO)
what is the definition of a UTI
an infection affecting the urinary tract (including kidneys, bladder, prostate, testis and epididymis)
what are the two things that are required for a diagnosis of a UTI
microbiological evidence AND symptoms/signs
what microbial evidence is needed for a UTI diagnosis
Bacterial count of 104 cfu/ml from MSSU specimen with no more than two species of micro-organisms
what symptoms/signs are needed for a UTI diagnosis
At least one of the following:
- Fever >38ºC
- loin/flank pain or tenderness
- suprapubic pain or tenderness
- urinary frequency
- urinary urgency
- dysuria
what are the two types of UTI
uncomplicated - young sexually active females only with clear relation to sexual activity
complicated** - everyone else
**complicated UTIs ALWAYS need to be investigated
what factors need to be considered for differentiating between complicated and uncomplicated UTI
- 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)
UTIs have different names depending on the organ affected - name the following:
bladder, prostate, kidney, testis
bladder - cystitis
prostate - prostatitis
kidney - pyelonephritis
testis - orchitis
what are complications of UTI
- infective: sepsis (esp. pyelonephritis), perinephric abscess
- renal failure (scarring)
- bladder malignancy (squamous cell carcinoma)
- acute urinary retention
- frank haematuria
- bladder or renal stones
what investigations are used for upper and lower UTI
MSSU/CSU
what investigations are used for lower tract UTI
flow studies, residual bladder scan, cystoscopy
what investigations are used for upper tract UTI
USS kidneys, IVU/CT-KUB, MAG-3 renogram, DMSA scan
what is the treatment for UTI
- Appropriate antibiotic therapy (type? duration? route?)
- Treat complications and cause
list soe emergencies related to urinary tract disease
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
what are the organisms associated with UTIs
E. coli Staph. saprophyticus Klebsiella Proteus Pseudomonas Staph aureus)
