Presentation of Diseases of the Kidneys and Urinary Tract 2020 pre-lecture version Flashcards
what makes up the upper urinary tract?
- Kidneys
- Parenchyma
- Pelvi-calyceal system - Ureters
- Pelvi-ureteric junction
- Ureter
- Vesico-ureteric junction
what makes up the lower urinary tract?
- Bladder
- Bladder outflow tract
- Bladder neck (intrinsic urethral sphincter)
- Prostate
- External urethral sphincter/pelvic floor
- Urethra
- Urethral meatus
- Foreskin
study this picture showing the anatomy of the kidney
Upper urinary tract disease: Kidney
what is in a surgical sieve?
- Infection
- Inflammation
- Iatrogenic
- Neoplasia
- Trauma
- Degenerative
- Congenital
- Genetic/Hereditary
- Vascular
- Endocrine
- Failure
- Idiopathic
- Etc.
what may the nature of renal diseases be?
- Infection
- Inflammation
- Iatrogenic
- Neoplasia
- Trauma
- Vascular
- Hereditary
nature of renal diseases:
what is an exmaple of infection?
•pyelonephritis
nature of renal diseases:
what is an exmaple of inflammation?
•glomerulonephritis, tubulointerstitial nephritis
nature of renal diseases:
what is an exmaple of iatrogenic?
nephrotoxicity, PCNL (surgery to remove stones form the kidney, drill big hole into the kidneys and can cause damage)
nature of renal diseases:
what is an exmaple of neoplasia?
renal tumours, collecting system tumours
nature of renal diseases:
what is an exmaple of trauma?
blunt trauma
nature of renal diseases:
what is an exmaple of vascular origin?
atherosclerosis, hypertension, diabetes
nature of renal diseases:
what is an exmaple of heriditary cause?
polycystic kidney disease, nephrotic syndrome
what is the presentation of renal diseases?
- Pain
- Pyrexia
- Haematuria
- Proteinuria
- Pyuria
- Mass on palpation
- Renal failure
- What is the definition of proteinuria?
a. Presence of protein in urine
b. Presence of albumin in urine
c. Urinary protein excretion >1mg/day
d. Urinary protein excretion >150mg/day
e. Urinary protein excretion >15g/day
Everyone secretes protein in urine so cant be A
Answer = D
- How many types of haematuria are there?
a. One
b. Two
c. Three
d. Four
e. Five
Macroscopic – gross or frank haematuria
Microscopic – examined under microscope and can see the cells
Dipstick positive haematuria
Answer = C
- The definition of microscopic haematuria is:
a. ≥1 red blood cells per high power field
b. ≥2 red blood cells per high power field
c. ≥3 red blood cells per high power field
d. ≥4 red blood cells per high power field
e. ≥5 red blood cells per high power field
Answer = C
Urine output: Definitions:
What is Oliguria?
Urine output <0.5ml/kg/hour
Urine output: Definitions:
What is Anuria?
Absolute anuria - No urine output; Relative anuria - <100ml/24 hours
failure of the kidneys to produce urine
Urine output: Definitions:
What is Polyuria?
Urine output >3L/24 hours
Urine output: Definitions:
What is Nocturia?
Waking up at night ≥1 occasion to micturate
Urine output: Definitions:
What is Nocturnal polyuria?
Nocturnal urine output >1/3 of total urine output in 24 hours
Acute Kidney Injury (AKI) (ARF) - what is the definiton in terms of staging?
- 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
presentation of chronic renal failure - what are the functionns of the kidneys?
one function of the kidney is body fluid homeostasis, what is an example of this?
fluid overload (peripheral oedema, congestive cardiac failure, pulmonary oedema)
one function of the kidney is electrolyte homeostasis, name examples of this?
Na+
K+
Cl-
etc
one function of the kidney is acid-base homeostasis, name examples of this?
excrete H+
generate HCO3-
one function of the kidney is regulation of vascular tone, what is an example of this?
regulation of blood pressure
one function of the kidney is regulation of excretory functions, what is an example of this?
physiological waste (esp. urea)
drugs
one function of the kidney is endocrine functions, what are examples of this?
erythropoeitin
vitamin D metab
renin
what is the presentation 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 the different natures of ureteric diseases?
infection
iatrogenic/trauma
neoplasia
hereditary
obstruction
the nature of ureteric disease may be infection, what is an example of this?
ureteritis
the nature of ureteric disease may be iatrogenic/trauma, what is an example of this?
inadvertently cut or tied during hysterectomy or colon resection
the nature of ureteric disease may be neoplasia, what are examples of this?
TCC of ureter, TCC of bladder obstructing VUJ, prostate cancer obstructing VUJ, pelvic malignancy, pelvic or para-aortic lymphadenopathy
the nature of ureteric disease may be hereditary, what are examples of this?
PUJ obstruction, VUJ reflux
the nature of ureteric disease may be obstruction, what are examples of this?
intra-luminal (stone, blood clot)
intra-mural (scar tissue, TCC)
extra-luminal (pelvic mass, lymph nodes)
what is the presentation of ureteric diseases?
- Pain (eg. renal colic)
- Pyrexia
- Haematuria
- Palpable mass (ie. hydronephrosis)
- Renal failure (only if bilateral obstruction or single functioning kidney)
what is the nature of bladder disease?
- 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
what is the presentation of bladder diseases?
- 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 frank haematuria?
a. 10-15%
b. 15-20%
c. 20-25%
d. 25-30%
e. 30-35%
D
- What is the risk of renal cancer in a patient who presents with frank haematuria?
a. 0-0.5%
b. 0.5-1.0%
c. 5-10%
d. 10-20%
e. 20-25%
C
what is shown here?
Endoscopic view of superficial TCC of bladder
Specimen of Bladder with solid TCC
Lower urinary tract symptoms (LUTS) (i.e. voiding LUTS, storage LUTS, incontinence, polyuria, etc.) can have multitude of causes, what are they?
- bladder pathology (OAB, UTI, interstitial cystitis, bladder cancer)
- bladder outflow obstruction
- pelvic floor dysfunction
- 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) - systemic disorders (e.g. chronic renal failure, cardiac failure, diabetes mellitus, diabetes insipidus)
what is the control of micturation done by?
1) Cortical centre (bladder sensation and conscious inhibition of micturition)
2) Pons (micturition centre) - main centre controlling voiding
3) Sacral segments (S2-S4) (micturition reflex):
- relaxation of internal urethral sphincter (autonomic - sympathetic)
- relaxation of external urethral sphincter (somatic)
- contraction of detrusor muscle (autonomic – parasympathetic)
What are the phases of the micturition cycle?
1) Storage (or filling) phase
2) Voiding phase
What are the different natures of bladder outflow tract diseases?
- 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
what are the presentations of bladder outflow tract diseases?
- 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 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 treatment for acute urinary retention?
- Immediate treatment is catheterisation (either urethral or suprapubic)
- Treat underlying trigger if present
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 causes chronic urinary retention and how does it present?
- 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)
- 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)
What is the treatment of chronic 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!)
- Immediate treatment is 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
If high-pressure chronic urinary retention, two types of diuresis may occur, what are they?
Physiological (usually <200ml/hour)
Pathological (usually >200ml/hour)
what is a UTI?
Defined as infection affecting urinary tract (including kidneys, bladder, prostate, testis and epididymis)
how do you diagnose a UTI?
• 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 the 2 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 some factors to consider in differentiating between complicated vs 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)
what does the presentation of UTIs depend on?
• Presentation depends on organ affected
- bladder (cystitis); prostate (prostatitis); kidney (pyelonephritis); testis (orchitis)
whata re 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 are the investigations for UTI?
- MSSU/CSU
- lower tract: flow studies, residual bladder scan, cystoscopy
- upper tract: USS kidneys, IVU/CT-KUB, MAG-3 renogram, DMSA scan
what is the treatment of UTI?
- Appropriate antibiotic therapy (type? duration? route?)
- Treat complications and cause
what are some emergencies related to UTI?
- 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 - Foreskin comes back and cant go forward again and causes ischemia
- Priapism - erection over 4 hours after sexual activity
- 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
- 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
top 3 are coliforms
Chlamydia is a sexual transited disease
E is an opportunistic organism
D is the correct answer
