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Urinary > Presentation of diseases of the kidneys and urinary tract > Flashcards

Presentation of diseases of the kidneys and urinary tract Flashcards

1
Q

describe the anatomy of the urinary tract?

A
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2
Q

what are the components of the upper urinary tract?

A
  1. Kidneys
    Parenchyma
    Pelvi-calyceal system
  2. Ureters
    Pelvi-ureteric junction
    Ureter
    Vesico-ureteric junction
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3
Q

what are the components of the lower urinary tract?

A
  1. Bladder
  2. Bladder outflow tract
    Bladder neck (intrinsic urethral sphincter)
    Prostate (men only)
    External urethral sphincter/pelvic floor
    Urethra
    Urinary meatus
    Foreskin (men only)
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4
Q

describe the anatomy of the kidney?

A
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5
Q

what is an infective causes of renal disease?

A

pylonephritis

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6
Q

what are inflammatory causes of renal disease?

A

glomerulonephritis, tubulointerstitial nephritis

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7
Q

what are iatrogenic causes of renal disease?

A

nephrotoxicity, PCNL

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8
Q

what are neoplastic causes of renal disease?

A

renal tumours, collecting system tumours

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9
Q

what are traumatic causes of renal disease?

A

blunt force trauma

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10
Q

what are vascular causes of renal disease?

A

atherosclerosis, hypertension, diabetes

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11
Q

what are hereditary causes of renal disease?

A

polycystic kidney disease, nephrotic syndrome

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12
Q

how do renal diseases present?

A

Pain

Pyrexia

Haematuria

Proteinuria

Pyuria - puss cells in urine

Mass on palpation

Renal failure

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13
Q

What is the definition of proteinuria?

A

Urinary protein excretion >150mg/day

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14
Q

In clinical practice, how many types of haematuria are there?

A

Three

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15
Q

what is the definition of microscopic haematuria?

A

≥3 red blood cells per high power field

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16
Q

what is oliguria?

A

Urine output <0.5ml/kg/hour

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17
Q

what is anuria?

A

Absolute anuria - No urine output; Relative anuria - <100ml/24 hours

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18
Q

what is polyuria?

A

Urine output >3L/24 hours

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19
Q

what is nocturia?

A

Waking up at night ≥1 occasion to micturate

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20
Q

what is nocturnal polyuria?

A

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

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21
Q

what is the definition of acute kidney injury in terms of staging - 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

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

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22
Q

risk

A

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

injury

A

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

failure

A

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

loss

A

Persistent ARF or complete loss of kidney function >4 weeks

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26
Q

end stage kidney disease

A

complete loss of kidney function >3 months

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27
Q

what are functions of the kidneys?

A
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28
Q

what are presenting features of chronic renal failure?

A

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)

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29
Q

what are infective causes of ureteric disease?

A

ureteritis

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30
Q

what are iatrogenic/traumatic causes of ureteric disease?

A

inadvertently cut or tied during hysterectomy or colon resection

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31
Q

what are neoplstic causes of ureteric disease?

A

TCC of ureter, TCC of bladder obstructing VUJ, prostate cancer obstructing VUJ, pelvic malignancy, pelvic or para-aortic lymphadenopathy

32
Q

what are hereditary causes of ureteric disease?

A

PUJ obstruction, VUJ reflux

33
Q

what are obstructive causes of ureteric disease?

A

intra-luminal (stone, blood clot)

intra-mural (scar tissue, TCC)
- extra-luminal (pelvic mass, lymph nodes)

34
Q

how do ureteric diseases present?

A

Pain (eg. renal colic)

Pyrexia

Haematuria

Palpable mass (ie. hydronephrosis)

Renal failure (only if bilateral obstruction or single functioning kidney)

35
Q

what are infective causes of bladder disease?

A

cystitis

36
Q

what are inflammatory causes of bladder diseases?

A

interstitial cystitis, colonic diverticulitis resulting in colo-vesical fistula

37
Q

what are iatrogenic/traumatic causes of bladder diseases?

A

bladder rupture, bladder injury from hysterectomy (resulting in vesico-vaginal fistula)

38
Q

what are neoplastic causes of bladder diseases?

A

TCC of bladder, squamous cell carcinoma of bladder

39
Q

what are idiopathic causes of bladder diseases?

A

overactive bladder syndrome

40
Q

what are degenerative causes of bladder disease?

A

chronic urinary retention

41
Q

what are neurological causes of bladder disease?

A

neurogenic bladder dysfunction

42
Q

how does bladder disease present?

A

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)

43
Q

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

A

25-30%

44
Q

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

A

0.5-1.0%

45
Q

Lower urinary tract symptoms (LUTS) (i.e. voiding LUTS, storage LUTS, incontinence, polyuria, etc.) can have multitude of causes:

A

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)

46
Q

neurological causes (i.e. neurogenic bladder dysfunction)?

A

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)

47
Q

what components of the brain are involved in control of micturation?

A
48
Q

what are infective causes of bladder outflow tract diseases?

A

prostatitis, balanitis

48
Q

what are iatrogenic/traumatic causes of bladder outflow tract diseases?

A

pelvic floor damage after traumatic vaginal delivery or hysterectomy, urethral injury from catheterisation or pelvic fracture

49
Q
A
50
Q

what are iatrgoenic causes of bladder outflow tract diseases?

A

pelvic floor damage after traumatic vaginal delivery or hysterectomy, urethral injury from catheterisation or pelvic fracture

50
Q

what are idiopathic causes of bladder outflow tract diseases?

A

chronic pelvic pain syndrome

50
Q

what are neoplastic causes of bladder outflow tract diseases?

A

prostate cancer, penile cancer

51
Q

what are obstrutcive causes of bladder outflow tract diseases?

A

primary bladder neck obstruction
- benign prostatic enlargement (BPE) causing obstruction
- urethral stricture
- meatal stenosis
- phimosis

51
Q

how do bladder outflow tract diseases present?

A

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

51
Q

what is acute urinary retention defined as?

A

painful inability to void with a palpable and percussible bladder’

Residuals vary from 500ml to 1 litre (but usually <1 litre)

51
Q

what is chronic urinary retention defined as?

A

‘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)

51
Q

what are complications of chronic urinary retention?

A

Complications: UTI, post-decompression haematuria, pathological diuresis, electrolyte abnormalities (hyponatraemia, hyperkalaemia, metabolic acidosis), persistent renal dysfunction due to acute tubular necrosis

52
Q

what is the main risk factor for acute urinary retention?

A

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)

52
Q

what is the main aetiolofical factor for 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)

52
Q

what is immediate treatment for chronic urinary retention?

A

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

52
Q

what is immediate treatment for acute urinary retention?

A

Immediate treatment is catheterisation (either urethral or suprapubic)

Treat underlying trigger if present

52
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

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!)

53
Q

If high-pressure chronic urinary retention, two types of diuresis may occur:

A
  • Physiological (usually <200ml/hour)
    • Pathological (usually >200ml/hour)
54
Q
A
55
Q

what is the definition of a uti?

A

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

56
Q

what does a diagnosis of a uti require?

A

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

57
Q

what are two types of utis?

A

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

58
Q

what are factors that need to be considered for utis?

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)
59
Q

what does presentation of a uti depend on?

A
  • bladder (cystitis); prostate (prostatitis); kidney (pyelonephritis); testis (orchitis)
60
Q

what are 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
61
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
62
Q
A
63
Q

what is treatment for a uti?

A

Treatment:
- Appropriate antibiotic therapy (type? duration? route?)
- Treat complications and cause

64
Q

what Emergencies related to urinary tract diseases?

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

65
Q

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

A

d. bladder volume >800ml

66
Q

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

A

d. Chlamydia trachomatis

Urinary (24 decks)

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