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12. Year 2: Urinary System > Presentation of Diseases of the Kidneys and Urinary Tract > Flashcards

Presentation of Diseases of the Kidneys and Urinary Tract Flashcards

1
Q

What can the urinary tract be divided into?

A
  • Upper urinary tract
    • Kidneys
      • Parenchyma
      • Pelvi-calyceal system
    • Ureters
      • Pelvi-ureteric junction
      • Ureter
      • Vesico-ureteric junction
  • Lower urinary tract
    • Bladder
    • Bladder outflow tract
      • Bladder neck (intrinsic urethral sphincter)
      • Prostate
      • External urethral sphincter/pelvic floor
      • Urethra
      • Urethral meatus
      • Foreskin
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2
Q

What is the upper urinary tract composed of?

A
  • Kidneys
    • Parenchyma
    • Pelvi-calyceal system
  • Ureters
    • Pelvi-ureteric junction
    • Ureter
    • Vesico-ureteric junction
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3
Q

What is the lower urinary tract composed of?

A
  • Bladder
  • Bladder outflow tract
    • Bladder neck (intrinsic urethral sphincter)
    • Prostate
    • External urethral sphincter/pelvic floor
    • Urethra
    • Urethral meatus
    • Foreskin
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4
Q

What structures form the bladder outflow tract of the lower urinary tract?

A
  • Bladder neck (intrinsic urethral sphincter)
  • Prostate
  • External urethral sphincter/pelvic floor
  • Urethra
  • Urethral meatus
  • Foreskin
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5
Q

What are some different classifications of diseases in general?

A
  • Infection
  • Inflammation
  • Iatrogenic
  • Neoplasia
  • Trauma
  • Degenerative
  • Congenital
  • Genetic/hereditary
  • Vascular
  • Endocrine
  • Failure
  • Idiopathic
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6
Q

What are the typical different classifications of kidney disease?

A
  • Infection
    • Pyelonephritis
  • Inflammation
    • Glomerulonephritis, tubulointerstitial nephritis
  • Iatrogenic
    • Nephrotoxicity, PCNL
  • Neoplasia
    • Renal tumours, collecting system tumours
  • Trauma
    • Blunt trauma
  • Vascular
    • Atherosclerosis, hypertension, diabetes
  • Hereditary
    • Polycystic kidney disease, nephrotic syndrome
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7
Q

What is the typical presentation of kidney disease?

A
  • Pain
  • Pyrexia
  • Haematuria
    • 2 types, microscopic and macroscopic
  • Proteinuria (presence of excess proteins in the urine)
  • Pyuria (presence of pus in urine)
  • Mass on palpation

Renal failure

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8
Q

What is the medical term for blood in the urine?

A

Haematuria

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9
Q

What is the medical term for the presence of pus in the urine?

A

Pyuria

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10
Q

What are the 2 types of haematuria?

A

Microscopic

Macroscopic

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11
Q

What are some different urine output definitions?

A

Oliguria = urine output <0.5ml/kg/hour

Anuria = two different kinds, absolute anuria (no urine output) or relative anuria (<100ml/24 hours)

Polyuria = urine out > 3L/24 hours

Nocturia = waking up at night 1 or more times to micturate

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

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12
Q

What is oliguria?

A

Oliguria = urine output <0.5ml/kg/hour

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13
Q

What is anuria?

A

Anuria = two different kinds, absolute anuria (no urine output) or relative anuria (<100ml/24 hours)

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14
Q

What are the 2 different kinds of anuria?

A

Absolute anuria

Relative anuria

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15
Q

What is polyuria?

A

Polyuria = urine out > 3L/24 hours

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16
Q

What is nocturia?

A

Nocturia = waking up at night 1 or more times to micturate

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17
Q

What is nocturnal polyuria?

A

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

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18
Q

How many stages of acute kidney injury (AKI) is there?

A

5

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19
Q

What does AKI stand for?

A

Acute kidney injury

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20
Q

What are the different stages of acute kidney injury?

A
  • Stage 1
    • Risk
    • Increase in serum creatinine level (1.5x) or decrease in GFR by 25% or UO <0.5ml/kg/h for 6 hours
  • Stage 2
    • Injury
    • Increase in serum creatinine level (2x) or decrease in GFR by 50% of UO <0.5ml/kg/h for 12 hours
  • Stage 3
    • Failure
    • Increase in serum creatinine level (3x) or decrease in GFR by 75% or serum creatinine level > 355umol/L with acute increase of >44umol/L or UO <0.3ml/kg/h for 24 hours or anuria for 12 hours
  • Stage 4
    • Loss
    • Persistent ARF or complete loss of kidney function > 4 weeks
  • Stage 5
    • End-stage kidney disease
    • Complete loss of kidney function > 3 months
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21
Q

What is stage 1 acute kidney injury?

A
  • Risk
  • Increase in serum creatinine level (1.5x) or decrease in GFR by 25% or UO <0.5ml/kg/h for 6 hours
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22
Q

What is stage 2 acute kidney injury?

A
  • Injury
  • Increase in serum creatinine level (2x) or decrease in GFR by 50% of UO <0.5ml/kg/h for 12 hours
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23
Q

What is stage 3 acute kidney injury?

A
  • Failure
  • Increase in serum creatinine level (3x) or decrease in GFR by 75% or serum creatinine level > 355umol/L with acute increase of >44umol/L or UO <0.3ml/kg/h for 24 hours or anuria for 12 hours
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24
Q

What is stage 4 acute kidney injury?

A
  • Loss
  • Persistent ARF or complete loss of kidney function > 4 weeks
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25
What is stage 5 acute kidney injury?
* End-stage kidney disease * Complete loss of kidney function \> 3 months
26
27
What is stage 5 acute kidney injury also known as?
End-stage kidney disease
28
What are some functions of the kidneys?
* Endocrine functions * Erythropoietin * Vitamin D metabolism * Renin * Excretory function * Physiological waste (especially urea) * Drugs * Regulation of vascular tone * Regulation of blood pressure * Acid-base homeostasis * Excrete H * Generate bicarbonate * Electrolyte homeostasis * Na * K * Cl * Body fluid homeostasis * Fluid overload (peripheral oedema, congestive cardiac failure, pulmonary oedema)
29
What is the presentation of chronic renal failure?
* Asymptomatic * Fatigue * Anaemia * Oedema * Hypertension * Bone pain due to renal bone disease * Pruritis (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)
30
What are some different classifications of ureteric diseases?
* Infection * Urethritis * Iatrogenic/trauma * Inadvertently cut or tied during hyperectomy or colon resection * Neoplasia * TCC of ureter * TCC of bladder obstruction VUJ * Prostate cancer obstructive VOJ * Pelvic malignancy * Pelvic or para-aortic lymphadenopathy * Hereditary * PUJ obstruction * VUJ reflux * Obstruction * Intra-liminal (stone, blood clot) * Intra-mural (scar tissue, TCC) * Extra-luminal (pelvic mass, lymph nodes)
31
What are some different exampls of ureteric diseases?
* Infection * Urethritis * Iatrogenic/trauma * Inadvertently cut or tied during hyperectomy or colon resection * Neoplasia * TCC of ureter * TCC of bladder obstruction VUJ * Prostate cancer obstructive VOJ * Pelvic malignancy * Pelvic or para-aortic lymphadenopathy * Hereditary * PUJ obstruction * VUJ reflux * Obstruction * Intra-liminal (stone, blood clot) * Intra-mural (scar tissue, TCC) * Extra-luminal (pelvic mass, lymph nodes)
32
What are some different examples of renal diseases?
* Infection * Pyelonephritis * Inflammation * Glomerulonephritis, tubulointerstitial nephritis * Iatrogenic * Nephrotoxicity, PCNL * Neoplasia * Renal tumours, collecting system tumours * Trauma * Blunt trauma * Vascular * Atherosclerosis, hypertension, diabetes * Hereditary * Polycystic kidney disease, nephrotic syndrome
33
What is the presentation of ureteric diseases?
* Pain * Pyrexia * Haematuria * Palpable mass * Renal failure (only if bilateral obstruction or single functioning kidney)
34
When can ureteric diseases cause renal failure?
Only if bilateral obstruction or single functioning kidney
35
What are the different classifications of bladder diseases?
* Infection * Cystitis * Inflammation * Interstitial cystitis * Colon diverticulitis resulting in colo-vesical fistula * Iatrogenic/trauma * Bladder rupture * Bladder injury from hyperectomy (resulting in vesico-vaginal fistula) * Neoplasia * TCC of bladder * Squamous cell carcinoma of blader * Idiopathic * Overreactive bladder syndrome * Degenerative * Chronic urinary retention * Neurological * Neurogenic bladder dysfunction
36
What are some examples of bladder diseases?
* Infection * Cystitis * Inflammation * Interstitial cystitis * Colon diverticulitis resulting in colo-vesical fistula * Iatrogenic/trauma * Bladder rupture * Bladder injury from hyperectomy (resulting in vesico-vaginal fistula) * Neoplasia * TCC of bladder * Squamous cell carcinoma of blader * Idiopathic * Overreactive bladder syndrome * Degenerative * Chronic urinary retention * Neurological * Neurogenic bladder dysfunction
37
What is the presentation of bladder diseases?
* Pain (suprapubic) * Pyrexia * Haematuria * Lower urinary tract symptoms (LUTS) * Storage LUTS (ie frequency, nocturia, urgency, urge incontinence) * Voiding LUTS (ie poor flow, intermittency, terminal dribbling) * Incontinence (stress, urge, overflow, neurogenic, dribbling) * Recurrent UTIs * Chronic urinary retention * Due to bladder underactivity * Urinary leak from vagina * Ie vesico-vaginal fistula * Pneumaturia * Ie colo-vesical fistula)
38
Where is the pain located associated with bladder diseases?
Suprapubic
39
What is the medical term for the passage of gas mixed with urine?
Pneumaturia
40
What does LUTS stand for?
Lower urinary tract symptoms
41
What are some examples of lower urinary tract symptoms (LUTS?
* Storage LUTS (ie frequency, nocturia, urgency, urge incontinence) * Voiding LUTS (ie poor flow, intermittency, terminal dribbling) * Incontinence (stress, urge, overflow, neurogenic, dribbling)
42
What are some examples of storage LUTS?
Frequency Nocturia Urgency Urge incontinence
43
What are some examples of voiding LUTS?
Poor flow Intermittency Terminal dribbling
44
What are some examples of incontinence LUTS?
Stress Urge Overflow Neurogenic Dribbling
45
What are some examples of causes of LUTS?
* Bladder pathology * OAB, UTI, interstitial cystitis, bladder cancer) * Bladder outflow obstruction * Pelvic floor dysfunction * Neurological cause * Neurogenic bladder dysfunction * Supra-pontine lesions (such as stroke, Alzheimer’s, PD) * Infra-pontine supra-sacral lesions (such as spinal cord injury, disc prolapse, spina bifida) * Infra-sacral (such as MS, diabetes, cauda equina compression, surgery to retroperitoneum) * Systemic disorders * Chronic renal failure, cardiac failure, diabetes mellitus, diabetes insipidus
46
What are some neurologicla causes of LUTS?
* Supra-pontine lesions (such as stroke, Alzheimer’s, PD) * Infra-pontine supra-sacral lesions (such as spinal cord injury, disc prolapse, spina bifida) * Infra-sacral (such as MS, diabetes, cauda equina compression, surgery to retroperitoneum)
47
What are some systemic disorders that can cause LUTS?
* Chronic renal failure, cardiac failure, diabetes mellitus, diabetes insipidus
48
What are some causes of supra-pontine lesions that can cause LUTS?
Stroke Alzheimers PD
49
What are some examples of infra-pontine supra-sacral lesions that can cause LUTS?
Spinal cord injury Disc prolapse Spina bifida
50
What are some examples of infra-sacral lesions that can cause LUTS?
MS Diabetes Cauda equina compression Surgery to retroperitoneal
51
Explain the control of micturition?
1. Cortical centre (bladder sensation and conscious inhibition of micturition) 2. Pons (micturition centre) 3. Sacral segments (S2-S4), micturition reflex 1. Relaxation of internal urethral sphincter (autonomic – sympathetic) 2. Relaxation of eternal urethral sphincter (somatic) 3. Contraction of detrusor muscle (autonomic – parasympathetic)
52
How does the cortical centre relate to micturition?
Responsible for bladder sensation and conscious inhibition of micturition
53
How does the pons relate to micturition
Micturition centre is in the pons
54
What parts of micturtion is the micrurition reflex responsible for?
1. Relaxation of internal urethral sphincter (autonomic – sympathetic) 2. Relaxation of eternal urethral sphincter (somatic) 3. Contraction of detrusor muscle (autonomic – parasympathetic)
55
What spinal levels are responsible for the micturition reflex?
S2-S4
56
What part of the nervous system is responsible for relaxation of internal urethral sphincter?
Autonomic - sympathetic
57
What part of the nervous system is responsible for relaxation of external urethral sphincter?
Somatic
58
What part of the nervous system is responsible for contraction of detrusor muscle?
Autonomic - parasympathetic
59
What are the different classifications of bladder outflow tract diseases?
* Infection/inflammation * Prostatitis * Balanitis * Iatrogenic/trauma * Pelvic floor damage after traumatic vaginal delivery or hyperectomy * 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 * Mental stenosis * Phimosis
60
What are some examples of bladder outflow tract diseases?
* Infection/inflammation * Prostatitis * Balanitis * Iatrogenic/trauma * Pelvic floor damage after traumatic vaginal delivery or hyperectomy * 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 * Mental stenosis * Phimosis
61
What is acute urinary retention?
Inability to voluntarily urinate
62
Is urinary retention detectable by examination of the patient?
Yes, it is palpable and percussible (the bladder)
63
What is the main factor for the aetiology of acure urinary retention?
* Main factor is detrusor underactivity which can be primary (such as primary bladder failure) or secondary (such as due to longstanding BOO, such as BPO or urethral stricture)
64
What is the presentation of acute urinary retention?
* LUTS or complications (such as bladder stones, UTI, overflow incontinence, post-renal or obstructive renal failure) or incidental finding * Defined as “painless, palpable and percussible bladder after voiding”
65
What can occur at the severe end of the spectrum of acute urinary retention?
Overflow incontinence and renal failure, when bladder capacity is reached and bladder prressure is in ecess of 25cm of water (ie chornic high-pressure urinary retention)
66
Do all patients with acute urinary retention need treatment?
Asymptomatic patients with low residuals not necessarily need treatment Patients with symptoms or complications need treatment (no role for medical therapy)
67
Is there a role for medical therapy in acute urinary retention?
No
68
What is the treatment for chronic urinary retention?
Immediate treatment is catheterisation (either urethral or suprapubic initially, followed by clean intermittent self-catheterization (CISC) if appropriate)
69
What does CISC stand for?
Clean intermittent self-catheterization
70
What are some 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
71
What are the 2 types of diuresis that may occur in high-pressure chronic urinary retention?
* Physiological (usually \<200ml/hour) * Pathological (usually \>200ml/hour
72
What is physiological diuresis in high-pressure chronic urinary retention defined as?
\<200ml/hour
73
What is pathological diuresis in high-pressure chronic urinary retention defined as?
\>200ml/hour
74
What does diagnosis of a urinary tract infection (UTI) require?
Diagnosis requires microbiological evidence and symptoms/signs: * Microbiological evidence * Bacterial count of 104 cfu/ml from MSSU specimen with no more than 2 species of micro-organisms * Symptoms/signs * At least one of the following * Fever \> 38oC * Loin/flank pain or tenderness * Suprapubic pain or tenderness * Urinary frequency * Urinary urgency * Dysuria
75
What does UTI stand for?
Urinary tract infection
76
What microbiological evidence is required to diagnose a UTI
* Bacterial count of 104 cfu/ml from MSSU specimen with no more than 2 species of micro-organisms
77
What symptoms/signs are required to confirm a UTI?
* At least one of the following * Fever \> 38oC * Loin/flank pain or tenderness * Suprapubic pain or tenderness * Urinary frequency * Urinary urgency * Dysuria
78
What are the 2 types of urinary tract infection?
* Uncomplicated UTIs * Young sexually active females only with clear relation to sexual activity * Complicated UTIs * Everyone else * Always need to be investigated
79
What are uncomplicated UTIs?
* Young sexually active females only with clear relation to sexual activity
80
What are complicated UTIs?
Everyone apart from young sexually active females only with clear relation to sexual activity
81
What are some factors to consider when differentiating between complicated and uncomplicated UTIs?
* Age * Sexual activity (females) * Gender * Co-morbidities (such as immunosuppression, renal failure, medications) * Abnormal renal tract (such as stones, renal outflow obstruction, BOO, horseshoe kidney, VU reflux, renal scarring, bladder tumour) * Foreign body (such as catheter, ureteric stent) * Types of organism * E coli, staph saprophyticus, Klebsiella, proteus, pseudomonas, staph aureas
82
What does the presentation of UTIs depend on?
* Bladder (cystitis) * Prostate (prostatitis) * Kidney (pyelonephritis) * Testes (orchitis)
83
What is inflammation of the bladder called?
Cystitis
84
What is inflammation of the prostate called?
Prostatitis
85
What is inflammation of the kidneys called?
Pyelonephritis
86
What is inflammation of the testes called?
Orchitis
87
What are some complications of UTIs?
* Infective * Sepsis (especially pyelonephritis), perinephric abscess * Renal failure * Scarring * Bladder malignancy * Squamous cell carcinoma (SCC) * Acute urinary retention * Frank haematuria * Bladder or renal stones
88
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
89
What is the treatment for UTIs?
* Appropriate antibiotic therapy (consider route, duration and type) * Treat complications and cause
90
What are some examples of medical emergencies related to urinary tract diseases?
* Acute renal failure * Sepsis due to UTI with or without lower urinary tract obstruction * Renal colic * Severe haematuria causing haemorrhagic shock * Metastatic diseases causing metabolic derangements (such as 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 * Priapism

12. Year 2: Urinary System (29 decks)

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