Presentation of Kidney + Urinary Tract Disease Flashcards by Sophia Boyce

What are the 2 components of the upper urinary tract?

Kidneys (parenchyma, pelvi-calyceal system) - Ureters (pelvi-ureteric junction, ureter, vesico-ureteric junction)

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What are the 2 components of the lower urinary tract?

Bladder - Bladder outflow tract (bladder neck, prostate, external urethral sphincter/pelvic floor, urethra, urethral meatus, foreskin)

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Give the various natures of renal diseases using a surgical sieve

IVINTHI Infection Vascular Inflammation Neoplasia Trauma Hereditary Iatrogenic

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Give examples for each of the 7 natures of renal diseases

IVINTHI Infection - pyelonephritis Vascular - atherosclerosis Inflammation - glomerulonephritis, tubulointerstitial nephritis Neoplasia - renal tumours, collecting system tumours Trauma - blunt trauma Hereditary - polycystic kidney disease, nephrotic syndrome Iatrogenic - nephrotoxicity, PCNL

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Name the various presentations of renal disease using a surgical sieve

4P Her Majesty Royal Pain Pyrexia Pyuria Proteinuria Haematuria Mass on palpation Renal failure

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How many mg/day is considered proteinuria?

>150mg

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Definition of microscopic haematuria is how many RBCs over a high power field?

5 or more

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What is oliguria defined as?

Urine output <0.5ml/kg/hr

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What is absolute anuria and relative anuria?

Absolute anuria - no urine output Relative anuria - <100ml/24 hrs

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What is polyuria defined as?

>3L/24 hrs

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What is nocturia defined as?

Waking up at night on 1 or more occasion to micturate

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What is nocturnal polyuria defined as?

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

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What is the stagng criteria for Acute Kidney Injury (AKI)

RIFLE

(Risk Injury Failure Loss End)

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Give the meaning for each of the RIFLE stages of AKI (ridiculous lol no way will they expect us to remember it all)

Risk - increase in serum creatinine (1.5x)/decrease in GFR by 25% or UO<0.5ml/kg/h for 6 hrs

Injury - increase in serum creatinine level (2.0x) or decrease in GFR by 50% or UO <0.5ml/kg/h for 12 hrs

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 <0.3ml/kg/h for 24 hrs, or anuria for 12 hrs

Loss - persistent ARF or complete loss of kidney function >4 months

End-stage kidney disease - complete loss of kidney function > 3 months

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Give the 6 key functions of the kidneys (3 homeostasis, 2 functions, 1 regulation)

Body fluid homeostasis - fluid overload (PerO, CHF, PulO)

Electrolyte homeostasis (Na+, K+, Cl- etc)

Acid-base homeostasis (excrete H+, generate HCO3-)

Regulation of vascular tone (BP)

Excretory functions (waste (esp urea), drugs)

Endocrine functions (EPO, vit D metab, renin)

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Try to name the presentations of chronic renal failure (think of functions)

Asymptomatic (found on blood/urine testing)

Tiredness

Anaemia

Oedema

High BP

Bone pain

In advanced renal failure - pruritus, nausea/vomiting, dyspnoea, pericarditis, neuropathy, coma

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Give the 5 types of nature of ureteric disease and examples of each

Infection - ureteritis
Iatrogenic/trauma - cut/tied during hysterectomy or colon resection
Neoplasia - TCC of ureter, TCC of bladder osbtructing VUJ, prostate cancer obstructing VUJ, pelvic malignancy, pelvic or para-aortic lymphadenopathy
Hereditary - PUJ obstruction, VUJ reflux
Obstruction - intra-luminal (stone, blood clot), intra-mural (scar tissue, TCC), extra-luminal (pelvic mass, lymph nods)

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What are the 5 presentations of ureteric disease?

Pain (e.g. renal colic)

Pyrexia

Haematuria

Palpable mass (e.g. hydronephrosis)

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

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Give the 7 types of nature of ureteric disease and examples of each

Infection - cystitis
Inflammation - interstitial cystitis, colonic diverticultisis = colo-vesical fistula
Iatrogenic/trauma - bladder rupture, bladder injury from hysterectomy (= vesico-vaginal fistula)
Neoplasia - TCC of bladder, SCC of bladder
Idiopathic - overactive bladder syndrome
Denegerative - chronic urinary retention
Neurological - neurogenic bladder dysfunction

What are the 8 presentations of bladder disease?

Pain

Pyrexia

Haematuria

Lower urinary tract symptoms (storage; voiding; incontinence)

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 are the types of haematuria?

Microscopic

Gross (frank/macroscopic)

What are 5 general causes of LUTS?

Bladder pathology (OAB, UTI, interstiital cystitis, bladder cancer)
Bladder outflow obstruction
Pelvic floor dysfunction
Neurological causes (i.e. neurogenic bladder dysfunction)
Systemic disorders (e.g. chronic renal failure, cardiac failure, diabetes mellitus, diabetes insipidus)

What are the 3 further neurological causes for LUTS

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)

What aspects of micturition is the cortical centre responsible for?

Bladder sensation and conscious inhibition of micturition

What is the pons called in terms of micturition?

Micturition centre

What are the sacral segments (S2-S4) responsible for in terms of micturition?

Micturition reflex

What are the 2 stages of the micturition cycle?

1) Storage (or filling) phase 2) Voiding phase

GIve the 5 types of nature of bladder outflow tract disease and examples of each

Infection/inflammation - prostatitis, balanitis Iatrogenic/trauma - pelvic floor damage after traumatic vaginal delivery or hysterectomy, urethral injury from catheterisation or pelvic fracture Neoplasia - prostate or penile cancer Idiopathic - chronic pelvic pain syndrome Obstruction - primary bladder neck obstruction, benign prostatic enlargement (BPE) causing obstruction, urethral structure, meatal stenosis, phimosis

Give the 7 presentations of bladder outflow tract diseases

Pain (suprapubic or perineal) Pyrexia Heamaturia LUTS (voiding; overflow incontinence, stess urinary incontinence) Recurrent UTI Acute urinary retention Chronic urinary retention

What is acute urinary retention defined as?

'painful inability to void with a palpable and percussable bladder'

Residuals in acute urinary retention vary from what?

500ml to 1L

Main risk factor for AUR and what is it triggered by?

Benign Prostatic Obstruction (BPO) but can also occur independently (e.g. UTI, urethral stricture, alcohol excess, post-op, acute surgical or medical problems) BPO usually triggered by unrelated event (e.g. constipation, alcohol excess, post-op causes, urological procedure)

Treatment for acute urianry retention?

Immediate catheterisation Treat underlying trigger

What is chronic urinary retention defined as?

'painless, palpable and percussable bladder after voiding'

Are patients with chronic urinary retention able to void?

Yes, patients often able to void but with residuals ranging from 400ml to \>2L depending on stage of condition

Main aetilogical factor for CUR?

*Detrusor underactivity* - can be primary (i.e. primary bladder failure) or secondary (i.e. due to longstanding BOO, e.g. BPO or urethral stricture)

What does CUR present as?

LUTS or complications (e.g. UTI, bladder stones, overflow incontinence, post-renal or obstructive renal failure) or incidental finding

When do overflow incontinence and renal failure occur in CUR?

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)

Treatment for CUR?

Asymptomatic patients with low residuals do not necessarily need treatment Patients with symptoms/complications need treatment Immediate treatment is catheterisation (either urethral or suprapubic initially, followed by CISC if appropriate)

Complications from CUR?

UTI post-decompression haematuria pathological diuresis electrolyte abnormalities persistent renal dysfunction due to acute tubular necrosis

If high-pressure CUR, 2 types of diuresis may occur, what are they?

- Physiological (usually \<200ml/hr) - Pathological (usually \>200ml/hr)

What r the 2 things required for a diagnosis of UTI?

1. Microbiological evidence (bacterial count 10⁴ cfu/ml from MSSU) 2. Symptoms/signs (at least one of fever, loin/flank pain/tenderness, suprapubic pain/tenderness, urinary frequency, urinary urgency, dysuria)

2 types of UTI?

i. Uncomplicated (young sexually active females only with clear relation to sexual activity) ii. Complicated (everyone else!)

Complications of UTI?

- Infective - sepsis, perinephric abscess - Renal failure - Bladder malignancy - Acute urianry retention - Frank haematuria - Bladder/renal stones

Investigations for UTI?

- MSSU/CSU - Lower tract - flow studies, residual blader scan, cytoscopy - Upper tract - USS kidneys, IVU/CT-KUB, MAG-3 renogram, DMSA scan

Treatment for UTI?

Appropriate abx Treat complications

Emergencies related to UTI? (loads!!)

* 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 of the penis, once retracted, cannot return to its original location * Priapism - painful and persistent erection of the penis