Presentation of Diseases of the Kidneys and Urinary Tract

Question 1

What is the upper urinary tract composed of?

Answer 1

• Kidneys & ureters

Question 2

What are some common symptoms in the presentation of renal diseases?

Answer 2

• Haematuria
• Proteinuria
• Pyuria (pus in urine)
• Renal failure
• Oliguria
• Anuria (don’t produce urine)

Question 3

How is acute kidney injury (AKI) staged?

Answer 3

RIFLE staging:

1. Risk: 1.5x increase creatinine or GFR decreased 25%
2. Injury: 2x increased creatinine or GFR decreased 50%
3. Failure: 3x creatinine or GFR decreased 75% or anuria for 12 hours
4. Loss: persistent loss of kidney function >4 weeks
5. End stage: loss of kidney function >3 months

Question 4

What are some of the major functions of the kidneys? (lack of these functions indicates kidney disease)

Answer 4

• Body fluid homeostasis
• Excretion
• Regulation of vascular tone
• Electrolyte homeostasis
• Acid base homeostasis (excrete H, generate HCO3)
• Endocrine functions (renin / erythropoeitin)

Question 5

What is the function of erythropoetin? Where is it produced? When is it released?

Answer 5

• produced in the kidneys and secreted in response to low blood oxygen
• travels to bone marrow where it stimulates stem cells to differentiate into RBC’s

Question 6

How does chronic renal failure tend to present? (symptoms / signs)

Answer 6

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)

Question 7

What are some common symptoms in the presentation of ureteric diseases?

Answer 7

• pain (renal colic)
• Pyrexia
• Haematuria
• Palpable mass
• Renal failure (if bilateral obstruction or only one functioning kidney)

Question 8

What are some common symptoms in the presentation of bladder diseases?

Answer 8

• Pain
• Pyrexia
• Haematuria
• Lower urinary tract symptoms (LUTS): poor voiding, incontinence, storage issues (nocturia)
• Recurrent UTIs
• Chronic urinary retention (can’t empty bladder)
• Urinary leak from vagina
• pneumaturia (gas in urine)

Question 9

What is a TCC in the bladder?

Answer 9

Transitional cell carcinoma

Question 10

Why are lower urinary tract symptoms a poor indicator of disease?

Answer 10

Because they can have a variety of causes:

• Bladder pathology
• Outflow tract pathology
• Pelvic floor dysfunction
• Neurological causes
• Systemic disorders

Question 11

Where / how is micturition controlled by the nervous system?

Answer 11

• Cortical centres: conscious inhibition of micturition
• Pons: micturition centre, relaxes urethral sphincter at initiation of micturition
• Sacral segments (S2-S4): micturition reflex

Question 12

Describe the micturition reflex at the sacral segments (S2-S4):

Answer 12

• Relaxation of internal urethral sphincter (sympathetic)
• Relaxation of external urethral sphincter (somatic)
• Contraction of detrusor muscle (parasympathetic)

Question 13

What are some common symptoms in the presentation of bladder outflow tract diseases?

Answer 13

• Pain
• Pyrexia
• Haematuria
• LUTS: voiding, incontinence
• Recurrent UTIs
• Acute urinary retention
• Chronic urinary retention

Question 14

What is the immediate treatment for acute urinary retention?

Answer 14

• Catheterization

Question 15

What is urinary retention?

Answer 15

• Inability to completely void the volume of the bladder

Question 16

Symptoms / signs of acute urinary retention? Chronic?

Answer 16

Acute: painful inability to void with a palpable and percussible bladder

Chronic: painless, palpable and percussible bladder after voiding

Question 17

What is the main cause of acute urinary retention? Chronic?

Answer 17

Acute: benign prostatic obstruction

Chronic: detrusor underactivity

Question 18

What is the most common cause of bladder outflow tract obstruction?

Answer 18

Benign prostatic enlargement

Question 19

What is required to make the diagnosis of urinary tract infection?

Answer 19

Symptoms & microbiological evidence
- Microbiological evidence: Bacterial count of 10^4 cfu/ml from MSSU specimen with no more than two species of micro-organisms

Question 20

What are the two types of UTI?

Answer 20

Uncomplicated: young sexually active females only with clear relation to sexual activity

Complicated: everyone else

Question 21

What are some possible complications associated with UTIs?

Answer 21

• infective: sepsis (esp. pyelonephritis)
• renal failure (scarring)
• bladder malignancy (squamous cell carcinoma)
• acute urinary retention
• frank haematuria
• bladder or renal stones

Question 22

What are the different types of haematuria?

Answer 22

• Visible (macroscopic)

- Non-visible (microscopic)

Question 23

Investigations for suspected UTI?

Answer 23

• MSSU/CSU
• lower tract: flow studies, residual bladder scan, cystoscopy
• upper tract: USS kidneys, IVU/CT-KUB, MAG-3 renogram, DMSA scan

Question 24

Treatment of UTI?

Answer 24

• Antibiotic therapy

- Treat underlying cause / complications