Presentation of Diseases of the Kidneys and Urinary Tract Flashcards
What is the end of the male urethra called?
Meatus = end of the urinary tract in males
What is Phimosis?
A congenital narrowing of the opening of the foreskin so that it cannot be retracted
What can phimosis cause?
Difficulty passing urine
Dysuria
Spray of stream
What are the 3 parts of the ureter route where a kidney stone can lodge?
Pelvi-ureteric junction
Pelvic Brim
Vesico-ureteric junction
What makes up the upper urinary tract?
Kidneys
- Parenchyma
- Pelvi-calyceal system
Ureters
- Pelvi-ureteric junction
- Ureter
- Vesico-ureteric junction
What forms the lower urinary tract?
Bladder
Bladder outflow tract
- Bladder neck (intrinsic urethral sphincter)
- Prostate
- External urethral sphincter/ pelvic floor
- Urethral
- Urethral meatus
- Foreskin
How does the bladder neck in males and females differ?
Intrinsic/ internal urethral sphincter natural tone is closed in males.
In females it is poorly developed and non functioning so they are totally dependent in their pelvic floor muscles
Why is continence effected in men who have their prostate removed?
How is this overcome?
Men who have their prostate removed also have part of bladder neck removed too (this removed the internal urethral sphincter.
Men now must (like women) rely on pelvic floor muscles for continence. In men however these muscles are inderdeveloped through lack of use.
Can train men to strengthen and use these muscles
What is a surgical sieve?
AIde memoir for differential diagnosis or aetiologies of a disease.
Give an example of a surgical sieve
MEDIC HAT PIN
Metabolic Endocrine Degenerative Infection/ inflammation Congenital/ Hereditary Haematological/ Vascular Autoimmune Psychological Idiopathic/ iatrogenic Neosplastic
Give some general presentations of kidney disease
Pain Pyrexia Haematuria Proteinuria Pyuria Mass on palpation Renal failure
What is the definition of proteinuria?
Urinary protein excretion >150mg/day
How many types of haematuria are there?
2:
- Frank/ Macroscopic
- Microscopic
Some will say there are 3 and that dip stick counts as a third
What is the definition of microscopic haematuria?
> /= 3 red blood cells per high power field
What is oliguria?
Urine output
What is anuria?
TWO TYPES
Absolute anuria:
-no urine output
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
In someone presenting with polyuria and polydipsia what should you exclude?
Chronic renal failure Hypokalaemia Hyperglycaemia Hypercalaemia Thyrotoxicosis Diuretics Diet
How do you stage acute renal failure/ acute kidney injury?
Mnemonic: RIFLE
Stage 1 (Risk) Stage 2 (Injury) Stage 3 (failure) Stage 4 (Loss) Stage 5 (End stage kidney disease)
What is the definition of stage 1 acute renal failure/ acute kidney injury?
Risk -
Increase in serum creatinine level (1.5x) or
Decrease in GFR by 25% or
What is the definition of stage 2 acute renal failure/ acute kidney injury?
Injury-
Increase in serum creatinine level (2.0x) or
Decrease in GFR by 50% or
Oliguria for 6 hours
-UO
What is the definition of stage 3 acute renal failure/ acute kidney injury?
Failure -
Increase in serum creatinine level (3.0x) or
Decrease in GFR by 75% or
Serum creatinine level >355umol/L with acute increase of >44umol/L or
UO
What is the definition of stage 4 acute renal failure/ acute kidney injury?
Loss -
Persistent ARF or complete loss of kidney function > 4 weeks
(damage permanent)
What is the definition of stage 5 acute renal failure/ acute kidney injury?
End stage kidney disease -
Complete loss of kidney function > 3 months
What are the functions of the kidney?
Body fluid homeostasis
Electrolyte homeostasis
Acid-base homeostasis
Regulation of vascular tone
Excretory functions
Endocrine functions
What does chronic renal failure effect?
Think of all the functions of the kidney
Will help you think of how it presents
Body fluid homeostasis
- Fluid overload
- –Peripheral oedema
- –Congestive cardiac failure
- –Pulmonary oedema
Electrolyte homeostasis
-Na+, K+, Cl- etc
Acid-Base Homeostasis
- Secrete H+
- Generate HCO3-
Regulation of vascular tone
-Regulation of BP
Excretory functions
- Physiological waste (esp. urea)
- Drugs
Endocrine functions
- Erythropoeitin
- Vitamin D metabolism
- Renin
How does chronic renal failure present?
Asymptomatic (found on blood and urine)
- Tiredness
- Anaemia
- Oedema
- High Blood Pressure
- Bone pain due to renal bone disease
In advanced renal failure:
- Pruritus
- Nausea an Vomiting
- Dyspnoea
- Pericarditis
- Neuropathy
- Coma
For obstruction in ureteric disease what should you consider?
Intra-luminal (Stone, blood clot)
Intra-mural (scar tissue, TCC)
Extra-luminal (pelvic mass, lymph nodes)
What does TCC stand for?
Transitional cell carcinoma
Give some general ways ureteric diseases may present
Pain (e.g. renal colic)
Pyrexia
Haematuria
Palpable mass (i.e. hydronephrosis)
Renal failure (only if bilateral obstruction or single functioning kidney)
What are the two types of neoplasia of the bladder?
Transitional cell carcinoma
Squamous cell carcinoma of bladder
Give some general ways bladder diseases may present
Pain (suprapubic)
Pyrexia
Haematuria
LUTS
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 pneumaturia?
Pneumaturia is the passage of gas or “air” in urine. This may be seen or described as “bubbles in the urine”.
What is LUTS?
Lower Urinary Tract Symptoms
2/3 Types:
- Storage LUTS:
- Voiding LUTS
-Incontinence
What is storage LUTS?
- Frequency
- Nocturia
- Urgency
- Urge incontinence
What is voiding LUTS?
- Poor flow
- Intermittency
- Terminal dribbling
Due to underactive bladder
What are the types of incontinence?
Stress Urge Mixed Overflow Neurogenic Dribbling
What is stress incontinence?
Occurs when you laugh, sneeze, cough, or otherwise exert pressure on your pelvic floor,
What is urge incontinence?
Occurs when you have a sudden and intense urge to urinate - even if you emptied your bladder a short while ago.
What is overflow incontinence?
Bladder doesn’t empty properly, small amounts dribble out involuntarily. You likely won’t sense that your bladder is full and will lose urine without noticing it. You also may feel as though your bladder is never empty.
What is mixed incontinence?
This most often involves characteristics of both stress and urge incontinence.
It can include leakage of varying degrees with strenuous physical activity (stress incontinence) and an overwhelmingly strong, sudden, uncontrollable urge to urinate immediately, a sensation that doesn’t let you make it to the toilet in time (urge incontinence).
What is the risk of bladder cancer in a patient who presents with frank haematuria?
20-25%
What is the risk of renal cancer in a patient who presents with frank haematuria?
0.5-1%
What are some of the multitude of causes of lower urinary tract symptoms?
Bladder pathology
-over active bladder, UTI, Interstitial cystitis, bladder cancer
Bladder outflow obstruction
Pevlic floor dysfunction
Neurological causes (i.e. neurogenic bladder dysfunction)
Systemic disorders
- Chronic renal failure
- Cardiac failure
- Diabetes mellitus
- Diabetes insipidus
What are some of the neurological causes of lower urinary tract symptoms?
Supra pontine lesions
-e.g. stroke, Alzhiemer’s, Parkinson’s
Infra-ponstin supra-sacral lesions
-e.g. spinal cord injury, disc prolapse, spina bifida
Infra-sacral
-e.g. MS, Diabetes, cauda equina compression, surgery to retroperitoneum
How does the cortical centre play into control of micturition?
Bladder sensation and conscious inhibition of micturition
How does the pons play into control of micturition?
Micturition centre
How do the sacral segments S2-S4 play into the control of micturition?
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 (or filling) phase
Voiding Phase
How may bladder outflow tract diseases present?
Pain (suprapubic or perineal)
Pyrexia
Haematuria
LUTS
- Voiding LUTS due to bladder outflow obstruction
- Overflow incontinence
- Stress urinary incontinence
Recurrent UTIs
Acute urinary retention
Chronic urinary retention
What is acute urinary tract retention described as?
Painful
Inability to void
Palpable and percussible bladder
How much does residual fluid vary in Acute urinary retention?
500ml to >1L depending on time lag in seeking medical attention
What is the main risk factor in acute urinary retention?
Benign Prostatic Obstruction (BPO)
But can also occur independently of BPO
- UTI
- Urethral stricture
- Alcohol excess
- Post-operative causes
- Acute surgical or medical problems
Fore those with benign prostate obstruction when can acute urinary retention occur?
Spontaneously
-Natural progression of BPO
Triggered by an unrelated event
- Constipation
- Alcohol excess
- Post-operative causes
- Urological procedure
What is the immediate treatment of acute urinary retention?
Catheterisation (either urethral or suprapubic)
once this has been done treat underlying trigger if present
What are the complications of acute urinary retention?
- UTI
- Post-decompensation haematoma
- Pathological diuresis
- Renal failure
- Electrolyte abnormalities
What is BPH and BPE?
BPH—benign prostatic hyperplasia, a term that should be used exclusively to describe the histologic changes characteristic of BPH.
BPE—benign prostatic enlargement, a term describing increased size of the gland usually secondary to BPH.
Approximately 50% of men with histologic BPH develop BPE.
If acute urinary retention is caused by benign prostatic enlargement how do you tackle it?
If acute urinary retention is due to benign prostatic enlargement (BPE) and no renal failure, start alpha blocker immediately and remove catheter in 2 days (60% will void successfully); if fail to void, recatheterise and organise TURP (after 6 weeks)
What is chronic urinary retention defined as?
Painless
Palpable and percussible bladder after voiding
Petients are often able to void but with residuals ranging from 400ml to >2 litres depending on stage of condition (i.e. wide spectrum)
What is the main aetiological factor of chronic urinary retention?
Detrusor underactivity which can be:
-Primary (i.e. primary bladder failure)
-Secondary (i.e. due to longstanding bladder outflow obstruction (BOO), such as benign prostatic obstruction (BPO) or urethral stricture)
How does chronic urinary retention present?
Presents as LUTS or complications (e.g. UTI, bladder stones, overflow incontinence, post-renal or obstructuve renal failure) or incidental finding
When do overflow incontinence and renal failure occur in chronic urinary retention?
Occur at severe end of spectrum, when bladder capacity is reached and bladder pressure is in excess of 25cm water (i.e. decompensated chronic urinary retention or acute-on-chronic urinary retention or chronic high-pressure urinary retention)
When do you treat chronic urinary retention?
Asymptomatic patients with low residuals do not neccessaritly need treatment
Patients with symptoms or clomplications need treatment (but no role for medical therapy)
What is the immediate treatment of chronic urinary retention?
Catheterisation (either urethral or suprapubic initially followed by CISC if appropriate)
What are the complications of chronic urinary retention?
UTI
Post-decompression haematuria
Pathological diuresis
Electrolyte abnormalities (Hyponatraemia, hyperkalaemia, metabolic acidosis)
Persistant renal dysfunction due to acute tubular necrosis
What are the pathological diuresis features of chronic urinary retention?
Urine output >200ml/hr +
Postural hypotension +
Weight loss+
Electrolyte abnormalities
What is the definition of postural hypotension?
Systolic differential >20mmHg between lying and standing
How do you manage pathological diuresis?
Manage with IV fluids (total input = 90% of output) and monitor closely; liase with renal team
What is the subsequent treatment of chronic urinary retention after immediate management?
Either long term urethral or suprapubic catheter, CISC or TURP if due to BPE
How does the effectivenes of TURP in chronic urinary retention compare to acute urinary retention?
TURP in chronic retention has a less successful outcome than for acute retention; however; patients with high pressure chronic retention has better outcome with TURP than patients with low pressure chronic retention
What is TURP?
Transurethral resection of the prostate (TURP) is a surgical procedure for men that involves removing part of the prostate gland. It’s often used to treat a common condition called benign prostatic hyperplasia (BPH), in which the prostate becomes enlarged, causing difficulties with passing urine.
What is CISC?
Clean intermittent self catheterisation
Clean Intermittent Self-Catheterization (CISC) is a way to empty the bladder by using a clean catheter. It involves putting the catheter in and taking it out several times a day. CISC helps people who cannot empty their bladders the usual way. By emptying your bladder regularly, you can help prevent bladder infections.
What are urinary tract infections defined as?
Infection affecting urinary tract (including kidneys, bladder, prostate, testis and epididymis)
What is required for a diagnosis of UTI?
Microbiological evidence AND symptoms/signs:
- Microbiological evidence: bacterial count of 10^4cfu/ml FROM MSSU SPECIMEN with no more than 2 species of micro-organism
- Symptoms/signs of at least ONE of the following:
- Fever >38 degrees;
- Loin/flank pain or tenderness
- Suprapubic pain or tenderness
- Urinary frequency
- Urinary urgency
- Dysuria
What are the two types of UTI?
Uncomplicated UTIs
-Young sexually active females only with clear relation to sexual activity
Complicated UTIs
- Everyone else
- Always need to be investigated
What factors should you consider when 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 organism (E. coli, Staph. sparophyticus, Klebsiella Proteus, Pseudomonas, Staoh aureus)
What does the presentation of UTI depend on?
Organ affected:
- Bladder (cystitis)
- Prostate (prostatitis)
- Kidney (pyelonephritis)
- Testes (Orchitis)
What is the definition of Recurrent UTI?
> 3 UTIs per year (or >2 in 6 months)
What is the definition of relapsed UTI?
UTI by same organism within 2 weeks of preceding UTI
usually indicative of inadequately treated UTI e.g. wrong antibiotic, dose or duration
What are the complications of UTI?
Infective:
- Sepsis (esp. pyelonephritis)
- Perinephric abscess
Renal failure (scarring)
Bladder malignancy (SCC)
Acute urinary retention
Frank haematuria
Bladder or renal stones
What are the investigations for UTI?
MSSU/ CSU
Lower tract:
- Flow studies
- Residual bladder scan
- Cytoscopy
Upper tract:
- 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
Give some emergencies related to UTI
Acute renal failure
Sepsis due to UTI +/- upper or lower urinary tract obstruction
Renal colic
Severe haematuria -> hypovolaemic shock
Metastatic disease causing:
- metabolic derangements (e.g. hypercalcaemia from bony mets),
- Spinal cord compression from vertebral mets
Acute urinary retention
Chronic high pressure urinary retention
Iatrogenic injury/ Trauma to upper or lower urinary tracts, penis and testes
Testicular torsion
Paraphimosis
Priapism
