Presentation of Kidney + Urinary Tract Disease Flashcards
What are the 2 components of the upper urinary tract?
- Kidneys (parenchyma, pelvi-calyceal system) - Ureters (pelvi-ureteric junction, ureter, vesico-ureteric junction)
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)
Give the various natures of renal diseases using a surgical sieve
IVINTHI Infection Vascular Inflammation Neoplasia Trauma Hereditary Iatrogenic
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
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
How many mg/day is considered proteinuria?
>150mg
Definition of microscopic haematuria is how many RBCs over a high power field?
5 or more
What is oliguria defined as?
Urine output <0.5ml/kg/hr
What is absolute anuria and relative anuria?
Absolute anuria - no urine output Relative anuria - <100ml/24 hrs
What is polyuria defined as?
>3L/24 hrs
What is nocturia defined as?
Waking up at night on 1 or more occasion to micturate
What is nocturnal polyuria defined as?
Nocturnal urine output >1/3 of total urine output in 24 hrs
What is the stagng criteria for Acute Kidney Injury (AKI)
RIFLE
(Risk Injury Failure Loss End)
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
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)
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
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)
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)
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?
- Microbiological evidence (bacterial count 104 cfu/ml from MSSU)
- 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
