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8. Urology (Medical Knowledge) > Presentation of Diseases of the Kidneys and Urinary Tract > Flashcards

Presentation of Diseases of the Kidneys and Urinary Tract Flashcards

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USMLE® Step 1 flashcards
1
Q

What can the urinary tract be divided into?

A
  • Upper urinary tract
    • Kidneys
      • Parenchyma
      • Pelvi-calyceal system
    • Ureters
      • Pelvi-ureteric junction
      • Ureter
      • Vesico-ureteric junction
  • Lower urinary tract
    • Bladder
    • Bladder outflow tract
      • Bladder neck (intrinsic urethral sphincter)
      • Prostate
      • External urethral sphincter/pelvic floor
      • Urethra
      • Urethral meatus
      • Foreskin
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2
Q

What is the upper urinary tract composed of?

A
  • Kidneys
    • Parenchyma
    • Pelvi-calyceal system
  • Ureters
    • Pelvi-ureteric junction
    • Ureter
    • Vesico-ureteric junction
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3
Q

What is the lower urinary tract composed 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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4
Q

What structures form the bladder outflow tract of the lower urinary tract?

A
  • Bladder neck (intrinsic urethral sphincter)
  • Prostate
  • External urethral sphincter/pelvic floor
  • Urethra
  • Urethral meatus
  • Foreskin
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5
Q

What are some different classifications of diseases in general?

A
  • Infection
  • Inflammation
  • Iatrogenic
  • Neoplasia
  • Trauma
  • Degenerative
  • Congenital
  • Genetic/hereditary
  • Vascular
  • Endocrine
  • Failure
  • Idiopathic
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6
Q

What are the typical different classifications of kidney disease?

A
  • 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
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7
Q

What is the typical presentation of kidney disease?

A
  • Pain
  • Pyrexia
  • Haematuria
    • 2 types, microscopic and macroscopic
  • Proteinuria (presence of excess proteins in the urine)
  • Pyuria (presence of pus in urine)
  • Mass on palpation

Renal failure

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8
Q

What is the medical term for blood in the urine?

A

Haematuria

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9
Q

What is the medical term for the presence of pus in the urine?

A

Pyuria

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10
Q

What are the 2 types of haematuria?

A

Microscopic

Macroscopic

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11
Q

What are some different urine output definitions?

A

Oliguria = urine output <0.5ml/kg/hour

Anuria = two different kinds, absolute anuria (no urine output) or relative anuria (<100ml/24 hours)

Polyuria = urine out > 3L/24 hours

Nocturia = waking up at night 1 or more times to micturate

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

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12
Q

What is oliguria?

A

Oliguria = urine output <0.5ml/kg/hour

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13
Q

What is anuria?

A

Anuria = two different kinds, absolute anuria (no urine output) or relative anuria (<100ml/24 hours)

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14
Q

What are the 2 different kinds of anuria?

A

Absolute anuria

Relative anuria

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15
Q

What is polyuria?

A

Polyuria = urine out > 3L/24 hours

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16
Q

What is nocturia?

A

Nocturia = waking up at night 1 or more times to micturate

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17
Q

What is nocturnal polyuria?

A

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

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18
Q

How many stages of acute kidney injury (AKI) is there?

A

5

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19
Q

What does AKI stand for?

A

Acute kidney injury

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20
Q

What are the different stages of acute kidney injury?

A
  • Stage 1
    • Risk
    • Increase in serum creatinine level (1.5x) or decrease in GFR by 25% or UO <0.5ml/kg/h for 6 hours
  • Stage 2
    • Injury
    • Increase in serum creatinine level (2x) or decrease in GFR by 50% of UO <0.5ml/kg/h for 12 hours
  • Stage 3
    • Failure
    • Increase in serum creatinine level (3x) or decrease in GFR by 75% or serum creatinine level > 355umol/L with acute increase of >44umol/L or UO <0.3ml/kg/h for 24 hours or anuria for 12 hours
  • Stage 4
    • Loss
    • Persistent ARF or complete loss of kidney function > 4 weeks
  • Stage 5
    • End-stage kidney disease
    • Complete loss of kidney function > 3 months
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21
Q

What is stage 1 acute kidney injury?

A
  • Risk
  • Increase in serum creatinine level (1.5x) or decrease in GFR by 25% or UO <0.5ml/kg/h for 6 hours
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22
Q

What is stage 2 acute kidney injury?

A
  • Injury
  • Increase in serum creatinine level (2x) or decrease in GFR by 50% of UO <0.5ml/kg/h for 12 hours
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23
Q

What is stage 3 acute kidney injury?

A
  • Failure
  • Increase in serum creatinine level (3x) or decrease in GFR by 75% or serum creatinine level > 355umol/L with acute increase of >44umol/L or UO <0.3ml/kg/h for 24 hours or anuria for 12 hours
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24
Q

What is stage 4 acute kidney injury?

A
  • Loss
  • Persistent ARF or complete loss of kidney function > 4 weeks
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25
Q

What is stage 5 acute kidney injury?

A
  • End-stage kidney disease
  • Complete loss of kidney function > 3 months
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26
Q
A
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27
Q

What is stage 5 acute kidney injury also known as?

A

End-stage kidney disease

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28
Q

What are some functions of the kidneys?

A
  • Endocrine functions
    • Erythropoietin
    • Vitamin D metabolism
    • Renin
  • Excretory function
    • Physiological waste (especially urea)
    • Drugs
  • Regulation of vascular tone
    • Regulation of blood pressure
  • Acid-base homeostasis
    • Excrete H
    • Generate bicarbonate
  • Electrolyte homeostasis
    • Na
    • K
    • Cl
  • Body fluid homeostasis
    • Fluid overload (peripheral oedema, congestive cardiac failure, pulmonary oedema)
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29
Q

What is the presentation of chronic renal failure?

A
  • Asymptomatic
  • Fatigue
  • Anaemia
  • Oedema
  • Hypertension
  • Bone pain due to renal bone disease
  • Pruritis (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)
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30
Q

What are some different classifications of ureteric diseases?

A
  • Infection
    • Urethritis
  • Iatrogenic/trauma
    • Inadvertently cut or tied during hyperectomy or colon resection
  • Neoplasia
    • TCC of ureter
    • TCC of bladder obstruction VUJ
    • Prostate cancer obstructive VOJ
    • Pelvic malignancy
    • Pelvic or para-aortic lymphadenopathy
  • Hereditary
    • PUJ obstruction
    • VUJ reflux
  • Obstruction
    • Intra-liminal (stone, blood clot)
    • Intra-mural (scar tissue, TCC)
    • Extra-luminal (pelvic mass, lymph nodes)
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31
Q

What are some different exampls of ureteric diseases?

A
  • Infection
    • Urethritis
  • Iatrogenic/trauma
    • Inadvertently cut or tied during hyperectomy or colon resection
  • Neoplasia
    • TCC of ureter
    • TCC of bladder obstruction VUJ
    • Prostate cancer obstructive VOJ
    • Pelvic malignancy
    • Pelvic or para-aortic lymphadenopathy
  • Hereditary
    • PUJ obstruction
    • VUJ reflux
  • Obstruction
    • Intra-liminal (stone, blood clot)
    • Intra-mural (scar tissue, TCC)
    • Extra-luminal (pelvic mass, lymph nodes)
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32
Q

What are some different examples of renal diseases?

A
  • 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
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33
Q

What is the presentation of ureteric diseases?

A
  • Pain
  • Pyrexia
  • Haematuria
  • Palpable mass
  • Renal failure (only if bilateral obstruction or single functioning kidney)
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34
Q

When can ureteric diseases cause renal failure?

A

Only if bilateral obstruction or single functioning kidney

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35
Q

What are the different classifications of bladder diseases?

A
  • Infection
    • Cystitis
  • Inflammation
    • Interstitial cystitis
    • Colon diverticulitis resulting in colo-vesical fistula
  • Iatrogenic/trauma
    • Bladder rupture
    • Bladder injury from hyperectomy (resulting in vesico-vaginal fistula)
  • Neoplasia
    • TCC of bladder
    • Squamous cell carcinoma of blader
  • Idiopathic
    • Overreactive bladder syndrome
  • Degenerative
    • Chronic urinary retention
  • Neurological
    • Neurogenic bladder dysfunction
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36
Q

What are some examples of bladder diseases?

A
  • Infection
    • Cystitis
  • Inflammation
    • Interstitial cystitis
    • Colon diverticulitis resulting in colo-vesical fistula
  • Iatrogenic/trauma
    • Bladder rupture
    • Bladder injury from hyperectomy (resulting in vesico-vaginal fistula)
  • Neoplasia
    • TCC of bladder
    • Squamous cell carcinoma of blader
  • Idiopathic
    • Overreactive bladder syndrome
  • Degenerative
    • Chronic urinary retention
  • Neurological
    • Neurogenic bladder dysfunction
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37
Q

What is the presentation of bladder diseases?

A
  • Pain (suprapubic)
  • Pyrexia
  • Haematuria
  • Lower urinary tract symptoms (LUTS)
    • Storage LUTS (ie frequency, nocturia, urgency, urge incontinence)
    • Voiding LUTS (ie poor flow, intermittency, terminal dribbling)
    • Incontinence (stress, urge, overflow, neurogenic, dribbling)
  • Recurrent UTIs
  • Chronic urinary retention
    • Due to bladder underactivity
  • Urinary leak from vagina
    • Ie vesico-vaginal fistula
  • Pneumaturia
    • Ie colo-vesical fistula)
38
Q

Where is the pain located associated with bladder diseases?

A

Suprapubic

39
Q

What is the medical term for the passage of gas mixed with urine?

A

Pneumaturia

40
Q

What does LUTS stand for?

A

Lower urinary tract symptoms

41
Q

What are some examples of lower urinary tract symptoms (LUTS?

A
  • Storage LUTS (ie frequency, nocturia, urgency, urge incontinence)
  • Voiding LUTS (ie poor flow, intermittency, terminal dribbling)
  • Incontinence (stress, urge, overflow, neurogenic, dribbling)
42
Q

What are some examples of storage LUTS?

A

Frequency

Nocturia

Urgency

Urge incontinence

43
Q

What are some examples of voiding LUTS?

A

Poor flow

Intermittency

Terminal dribbling

44
Q

What are some examples of incontinence LUTS?

A

Stress

Urge

Overflow

Neurogenic

Dribbling

45
Q

What are some examples of causes of LUTS?

A
  • Bladder pathology
    • OAB, UTI, interstitial cystitis, bladder cancer)
  • Bladder outflow obstruction
  • Pelvic floor dysfunction
  • Neurological cause
    • Neurogenic bladder dysfunction
      • Supra-pontine lesions (such as stroke, Alzheimer’s, PD)
      • Infra-pontine supra-sacral lesions (such as spinal cord injury, disc prolapse, spina bifida)
      • Infra-sacral (such as MS, diabetes, cauda equina compression, surgery to retroperitoneum)
  • Systemic disorders
    • Chronic renal failure, cardiac failure, diabetes mellitus, diabetes insipidus
46
Q

What are some neurologicla causes of LUTS?

A
  • Supra-pontine lesions (such as stroke, Alzheimer’s, PD)
  • Infra-pontine supra-sacral lesions (such as spinal cord injury, disc prolapse, spina bifida)
  • Infra-sacral (such as MS, diabetes, cauda equina compression, surgery to retroperitoneum)
47
Q

What are some systemic disorders that can cause LUTS?

A
  • Chronic renal failure, cardiac failure, diabetes mellitus, diabetes insipidus
48
Q

What are some causes of supra-pontine lesions that can cause LUTS?

A

Stroke

Alzheimers

PD

49
Q

What are some examples of infra-pontine supra-sacral lesions that can cause LUTS?

A

Spinal cord injury

Disc prolapse

Spina bifida

50
Q

What are some examples of infra-sacral lesions that can cause LUTS?

A

MS

Diabetes

Cauda equina compression

Surgery to retroperitoneal

51
Q

Explain the control of micturition?

A
  1. Cortical centre (bladder sensation and conscious inhibition of micturition)
  2. Pons (micturition centre)
  3. Sacral segments (S2-S4), micturition reflex
    1. Relaxation of internal urethral sphincter (autonomic – sympathetic)
    2. Relaxation of eternal urethral sphincter (somatic)
    3. Contraction of detrusor muscle (autonomic – parasympathetic)
52
Q

How does the cortical centre relate to micturition?

A

Responsible for bladder sensation and conscious inhibition of micturition

53
Q

How does the pons relate to micturition

A

Micturition centre is in the pons

54
Q

What parts of micturtion is the micrurition reflex responsible for?

A
  1. Relaxation of internal urethral sphincter (autonomic – sympathetic)
  2. Relaxation of eternal urethral sphincter (somatic)
  3. Contraction of detrusor muscle (autonomic – parasympathetic)
55
Q

What spinal levels are responsible for the micturition reflex?

A

S2-S4

56
Q

What part of the nervous system is responsible for relaxation of internal urethral sphincter?

A

Autonomic - sympathetic

57
Q

What part of the nervous system is responsible for relaxation of external urethral sphincter?

A

Somatic

58
Q

What part of the nervous system is responsible for contraction of detrusor muscle?

A

Autonomic - parasympathetic

59
Q

What are the different classifications of bladder outflow tract diseases?

A
  • Infection/inflammation
    • Prostatitis
    • Balanitis
  • Iatrogenic/trauma
    • Pelvic floor damage after traumatic vaginal delivery or hyperectomy
    • 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
    • Mental stenosis
    • Phimosis
60
Q

What are some examples of bladder outflow tract diseases?

A
  • Infection/inflammation
    • Prostatitis
    • Balanitis
  • Iatrogenic/trauma
    • Pelvic floor damage after traumatic vaginal delivery or hyperectomy
    • 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
    • Mental stenosis
    • Phimosis
61
Q

What is acute urinary retention?

A

Inability to voluntarily urinate

62
Q

Is urinary retention detectable by examination of the patient?

A

Yes, it is palpable and percussible (the bladder)

63
Q

What is the main factor for the aetiology of acure urinary retention?

A
  • Main factor is detrusor underactivity which can be primary (such as primary bladder failure) or secondary (such as due to longstanding BOO, such as BPO or urethral stricture)
64
Q

What is the presentation of acute urinary retention?

A
  • LUTS or complications (such as bladder stones, UTI, overflow incontinence, post-renal or obstructive renal failure) or incidental finding
  • Defined as “painless, palpable and percussible bladder after voiding”
65
Q

What can occur at the severe end of the spectrum of acute urinary retention?

A

Overflow incontinence and renal failure, when bladder capacity is reached and bladder prressure is in ecess of 25cm of water (ie chornic high-pressure urinary retention)

66
Q

Do all patients with acute urinary retention need treatment?

A

Asymptomatic patients with low residuals not necessarily need treatment

Patients with symptoms or complications need treatment (no role for medical therapy)

67
Q

Is there a role for medical therapy in acute urinary retention?

A

No

68
Q

What is the treatment for chronic urinary retention?

A

Immediate treatment is catheterisation (either urethral or suprapubic initially, followed by clean intermittent self-catheterization (CISC) if appropriate)

69
Q

What does CISC stand for?

A

Clean intermittent self-catheterization

70
Q

What are some 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 necrosis
71
Q

What are the 2 types of diuresis that may occur in high-pressure chronic urinary retention?

A
  • Physiological (usually <200ml/hour)
  • Pathological (usually >200ml/hour
72
Q

What is physiological diuresis in high-pressure chronic urinary retention defined as?

A

<200ml/hour

73
Q

What is pathological diuresis in high-pressure chronic urinary retention defined as?

A

>200ml/hour

74
Q

What does diagnosis of a urinary tract infection (UTI) require?

A

Diagnosis requires microbiological evidence and symptoms/signs:

  • Microbiological evidence
    • Bacterial count of 104 cfu/ml from MSSU specimen with no more than 2 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
75
Q

What does UTI stand for?

A

Urinary tract infection

76
Q

What microbiological evidence is required to diagnose a UTI

A
  • Bacterial count of 104 cfu/ml from MSSU specimen with no more than 2 species of micro-organisms
77
Q

What symptoms/signs are required to confirm a UTI?

A
  • At least one of the following
    • Fever > 38oC
    • Loin/flank pain or tenderness
    • Suprapubic pain or tenderness
    • Urinary frequency
    • Urinary urgency
    • Dysuria
78
Q

What are the 2 types of urinary tract infection?

A
  • Uncomplicated UTIs
    • Young sexually active females only with clear relation to sexual activity
  • Complicated UTIs
    • Everyone else
    • Always need to be investigated
79
Q

What are uncomplicated UTIs?

A
  • Young sexually active females only with clear relation to sexual activity
80
Q

What are complicated UTIs?

A

Everyone apart from young sexually active females only with clear relation to sexual activity

81
Q

What are some factors to consider when differentiating between complicated and uncomplicated UTIs?

A
  • Age
  • Sexual activity (females)
  • Gender
  • Co-morbidities (such as immunosuppression, renal failure, medications)
  • Abnormal renal tract (such as stones, renal outflow obstruction, BOO, horseshoe kidney, VU reflux, renal scarring, bladder tumour)
  • Foreign body (such as catheter, ureteric stent)
  • Types of organism
    • E coli, staph saprophyticus, Klebsiella, proteus, pseudomonas, staph aureas
82
Q

What does the presentation of UTIs depend on?

A
  • Bladder (cystitis)
  • Prostate (prostatitis)
  • Kidney (pyelonephritis)
  • Testes (orchitis)
83
Q

What is inflammation of the bladder called?

A

Cystitis

84
Q

What is inflammation of the prostate called?

A

Prostatitis

85
Q

What is inflammation of the kidneys called?

A

Pyelonephritis

86
Q

What is inflammation of the testes called?

A

Orchitis

87
Q

What are some complications of UTIs?

A
  • Infective
    • Sepsis (especially pyelonephritis), perinephric abscess
  • Renal failure
    • Scarring
  • Bladder malignancy
    • Squamous cell carcinoma (SCC)
  • Acute urinary retention
  • Frank haematuria
  • Bladder or renal stones
88
Q

What investigations are done for UTIs?

A
  • MSSU/CSU
  • Lower tract
    • Flow studies, residual bladder scan, cystoscopy
  • Upper tract
    • USS kidneys, IVU/CT-KUB, MAG-3 renogram, DMSA scan
89
Q

What is the treatment for UTIs?

A
  • Appropriate antibiotic therapy (consider route, duration and type)
  • Treat complications and cause
90
Q

What are some examples of medical emergencies related to urinary tract diseases?

A
  • Acute renal failure
  • Sepsis due to UTI with or without lower urinary tract obstruction
  • Renal colic
  • Severe haematuria causing haemorrhagic shock
  • Metastatic diseases causing metabolic derangements (such as 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

8. Urology (Medical Knowledge) (17 decks)

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