Presentation of diseases of the kidneys and urinary tract Flashcards
describe the anatomy of the urinary tract?
what are the components of the upper urinary tract?
- Kidneys
Parenchyma
Pelvi-calyceal system - Ureters
Pelvi-ureteric junction
Ureter
Vesico-ureteric junction
what are the components of the lower urinary tract?
- Bladder
- Bladder outflow tract
Bladder neck (intrinsic urethral sphincter)
Prostate (men only)
External urethral sphincter/pelvic floor
Urethra
Urinary meatus
Foreskin (men only)
describe the anatomy of the kidney?
what is an infective causes of renal disease?
pylonephritis
what are inflammatory causes of renal disease?
glomerulonephritis, tubulointerstitial nephritis
what are iatrogenic causes of renal disease?
nephrotoxicity, PCNL
what are neoplastic causes of renal disease?
renal tumours, collecting system tumours
what are traumatic causes of renal disease?
blunt force trauma
what are vascular causes of renal disease?
atherosclerosis, hypertension, diabetes
what are hereditary causes of renal disease?
polycystic kidney disease, nephrotic syndrome
how do renal diseases present?
Pain
Pyrexia
Haematuria
Proteinuria
Pyuria - puss cells in urine
Mass on palpation
Renal failure
What is the definition of proteinuria?
Urinary protein excretion >150mg/day
In clinical practice, how many types of haematuria are there?
Three
what is the definition of microscopic haematuria?
≥3 red blood cells per high power field
what is oliguria?
Urine output <0.5ml/kg/hour
what is anuria?
Absolute anuria - No urine output; Relative anuria - <100ml/24 hours
what is polyuria?
Urine output >3L/24 hours
what is nocturia?
Waking up at night ≥1 occasion to micturate
what is nocturnal polyuria?
Nocturnal urine output >1/3 of total urine output in 24 hours
what is the definition of acute kidney injury in terms of staging - RIFLE?
Risk - Increase in serum creatinine level (1.5x) or decrease in GFR by 25%, or UO <0.5 mL/kg/h for 6 hours
Injury - Increase in serum creatinine level (2.0x) or decrease in GFR by 50%, or UO <0.5 mL/kg/h for 12 hours
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
Loss - Persistent ARF or complete loss of kidney function >4 weeks
End-stage kidney disease - complete loss of kidney function >3 months
risk
Increase in serum creatinine level (1.5x) or decrease in GFR by 25%, or UO <0.5 mL/kg/h for 6 hours
injury
Increase in serum creatinine level (2.0x) or decrease in GFR by 50%, or UO <0.5 mL/kg/h for 12 hours
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
loss
Persistent ARF or complete loss of kidney function >4 weeks
end stage kidney disease
complete loss of kidney function >3 months
what are functions of the kidneys?
what are presenting features of chronic renal failure?
Asymptomatic (found on blood and urine testing)
Tiredness
Anaemia
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 infective causes of ureteric disease?
ureteritis
what are iatrogenic/traumatic causes of ureteric disease?
inadvertently cut or tied during hysterectomy or colon resection
what are neoplstic causes of ureteric disease?
TCC of ureter, TCC of bladder obstructing VUJ, prostate cancer obstructing VUJ, pelvic malignancy, pelvic or para-aortic lymphadenopathy
what are hereditary causes of ureteric disease?
PUJ obstruction, VUJ reflux
what are obstructive causes of ureteric disease?
intra-luminal (stone, blood clot)
intra-mural (scar tissue, TCC)
- extra-luminal (pelvic mass, lymph nodes)
how do ureteric diseases present?
Pain (eg. renal colic)
Pyrexia
Haematuria
Palpable mass (ie. hydronephrosis)
Renal failure (only if bilateral obstruction or single functioning kidney)
what are infective causes of bladder disease?
cystitis
what are inflammatory causes of bladder diseases?
interstitial cystitis, colonic diverticulitis resulting in colo-vesical fistula
what are iatrogenic/traumatic causes of bladder diseases?
bladder rupture, bladder injury from hysterectomy (resulting in vesico-vaginal fistula)
what are neoplastic causes of bladder diseases?
TCC of bladder, squamous cell carcinoma of bladder
what are idiopathic causes of bladder diseases?
overactive bladder syndrome
what are degenerative causes of bladder disease?
chronic urinary retention
what are neurological causes of bladder disease?
neurogenic bladder dysfunction
how does bladder disease present?
Pain (suprapubic)
Pyrexia
Haematuria
Lower urinary tract symptoms (LUTS)
- storage LUTS (i.e. frequency, nocturia, urgency, urge incontinence)
- voiding LUTS (i.e. poor flow, intermittency, terminal dribbling) – due to underactive bladder
- incontinence (stress, urge, mixed, overflow, neurogenic, dribbling, etc.)
Recurrent UTIs
Chronic urinary retention (due to bladder underactivity)
Urinary leak from vagina (i.e. vesico-vaginal fistula)
Pneumaturia (i.e. colo-vesical fistula)
What is the risk of bladder cancer in a patient who presents with visible haematuria?
25-30%
What is the risk of renal cancer in a patient who presents with visible haematuria?
0.5-1.0%
Lower urinary tract symptoms (LUTS) (i.e. voiding LUTS, storage LUTS, incontinence, polyuria, etc.) can have multitude of causes:
bladder pathology (OAB, UTI, interstitial cystitis, bladder cancer)
- bladder outflow obstruction
- pelvic floor dysfunction
- neurological causes (i.e. neurogenic bladder dysfunction)
- systemic disroders (e.g. chronic renal failure, cardiac failure, diabetes
mellitus, diabetes insipidus)
neurological causes (i.e. neurogenic bladder dysfunction)?
i. supra-pontine lesions (e.g. stroke, Alzheimer’s, Parkinson’s)
ii. infra-pontine supra-sacral lesions (e.g. spinal cord injury, disc prolapse, spina bifida)
iii. infra-sacral (e.g. multiple sclerosis, diabetes, cauda equina compression, surgery to retroperitoneum)
what components of the brain are involved in control of micturation?
what are infective causes of bladder outflow tract diseases?
prostatitis, balanitis
what are iatrogenic/traumatic causes of bladder outflow tract diseases?
pelvic floor damage after traumatic vaginal delivery or hysterectomy, urethral injury from catheterisation or pelvic fracture
what are iatrgoenic causes of bladder outflow tract diseases?
pelvic floor damage after traumatic vaginal delivery or hysterectomy, urethral injury from catheterisation or pelvic fracture
what are idiopathic causes of bladder outflow tract diseases?
chronic pelvic pain syndrome
what are neoplastic causes of bladder outflow tract diseases?
prostate cancer, penile cancer
what are obstrutcive causes of bladder outflow tract diseases?
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
Lower urinary tract symptoms (LUTS)
- voiding LUTS (i.e. hesitancy, intermittency, poor flow, terminal dribbling, incomplete bladder emptying) due to Bladder Outflow Obstruction (BOO)
- overflow incontinence (high-pressure chronic urinary retention)
- stress urinary incontinence
Recurrent UTIs
Acute urinary retention
Chronic urinary retention
what is acute urinary retention defined as?
painful inability to void with a palpable and percussible bladder’
Residuals vary from 500ml to 1 litre (but usually <1 litre)
what is chronic urinary retention defined as?
‘painless, palpable and percussible bladder after voiding’
Patients often able to void but with residuals ranging from 400ml to >2 litres depending on stage of condition (i.e. wide spectrum)
what are complications of chronic urinary retention?
Complications: UTI, post-decompression haematuria, pathological diuresis, electrolyte abnormalities (hyponatraemia, hyperkalaemia, metabolic acidosis), persistent renal dysfunction due to acute tubular necrosis
what is the main risk factor for acute urinary retention?
Main risk factor is Benign Prostatic Obstruction (BPO) but can also occur independently of BPO (eg. UTI, urethral stricture, alcohol excess, post-operative causes, acute surgical or medical problems)
For those with BPO, usually triggered by an unrelated event (eg. constipation, alcohol excess, post-operative causes, urological procedure)
what is the main aetiolofical factor for chronic urinary retention?
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)
what is immediate treatment for chronic urinary retention?
Immediate treatment is catheterisation (either urethral or suprapubic initially, followed by CISC if appropriate)
what is immediate treatment for acute urinary retention?
Immediate treatment is catheterisation (either urethral or suprapubic)
Treat underlying trigger if present
how does chronic urinary retention present?
Presents as LUTS or complications (e.g. UTI, bladder stones, overflow incontinence, post-renal or obstructive renal failure) or incidental finding
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. chronic high-pressure urinary retention)
Asymptomatic patients with low residuals do not necessarily need treatment
Patients with symptoms or complications need treatment (but no role for medical therapy!)
If high-pressure chronic urinary retention, two types of diuresis may occur:
- Physiological (usually <200ml/hour)
- Pathological (usually >200ml/hour)
what is the definition of a uti?
Defined as infection affecting urinary tract (including kidneys, bladder, prostate, testis and epididymis)
what does a diagnosis of a uti require?
A diagnosis requires microbiological evidence AND symptoms/signs:
i. Microbiological evidence: Bacterial count of 104 cfu/ml from MSSU specimen with
no more than two species of micro-organisms
ii. Symptoms/signs: At least one of the following: Fever >38ºC; loin/flank pain or
tenderness; suprapubic pain or tenderness; urinary frequency; urinary urgency; dysuria
what are two types of utis?
i. Uncomplicated UTIs (young sexually active females only with clear relation to sexual activity)
ii. Complicated UTIs (everyone else!)
Complicated UTIs always need to be investigated
what are factors that need to be considered for utis?
- 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)
what does presentation of a uti depend on?
- 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 done for utis?
- MSSU/CSU
- lower tract: flow studies, residual bladder scan, cystoscopy
- upper tract: USS kidneys, IVU/CT-KUB, MAG-3 renogram, DMSA scan
what is treatment for a uti?
Treatment:
- Appropriate antibiotic therapy (type? duration? route?)
- Treat complications and cause
what Emergencies related to urinary tract diseases?
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
The following are essential features of acute urinary retention except:
a. painful
b. palpable bladder
c. inability to urinate
d. bladder volume >800ml
e. percussible bladder
d. bladder volume >800ml
The following organisms are commonly associated with urinary tract infections except:
a. E. coli
b. Klebsiella species
c. Proteus species
d. Chlamydia trachomatis
e. Pseudomonas aeruginosa
d. Chlamydia trachomatis
