- RENAL AND GENITOURINARY PRESENTATIONS - Flashcards
Describe the physiological mechanisms of fluid regulation
- Fluid placement (ECF, ICF, IVF)
- Fluid and electrolyte balance
- ADH
- RAAS
- Osmolarity
Describe the autoregulation of renal blood flow
- tubuloglomerular feedback maintains stable GFR despite changes in systemic BP
1. Increase in blood flow in the afferent arteriole
2. increase in glomerular filtration rate (>125mls/min)
3. Increase in NaCl delivery to the macular densa cells
4. Excess Na conc. causes an increase in ATP release into the interstitium
5. ATP is converted into Adenosine
6. Adenosine activates G protein pathway in the Extraglomerular mesangial cells causing the production of Ca
7. Increase in intracellular calcium travels into the juxtoglomerular cells via gap junctions, as well as into the smooth muscle cells - causing the cell to contract and the afferent arteriole to constrict, reducing the GFR
8. Calcium also stimulates the release of renin into the afferent arteriole from the juxtoglomerular cells
9. causing a further decrease in GFR
Describe the neural regulation of renal blood flow
- juxtoglomerular cells stimulate changes in tone of afferent and efferent arterioles
Describe the hormonal regulation of renal blood flow
- renin release is in response to renal blood flow; ADH release is in response to osmolality
Outline the causes of acute urinary retention
- prostate abnormalities
- impaired bladder contractility,
- detrusor-sphincter dyssynergia (lack of coordination between bladder contraction and sphincter relaxation)
- drugs: especially with anticholinergic effect
- severe faecal impaction
- neurogenic bladder – diabetes, MS, Parkinson’s
Outline the causes of renal calculi
- dehydration
- UTI
- gout
- family history
- hypercalciuria
Outline the causes of paraphimosis
- Direct trauma to the area
- Failure to return the foreskin to its normal location after urination or washing (most common in hospitals and nursing homes)
- Infection, which may be due to poor personal hygiene
Outline the causes of priaprism
- Alcohol or drug abuse (especially cocaine)
- Certain medications, including some antidepressants and blood pressure medications
- Spinal cord problems
- Injury to the genitals
- Anesthesia
- Penile injection therapy (a treatment for erectile dysfunction)
- Blood diseases, including leukemia and sickle cell anaemia
Outline the causes of testicular torsion
deformity of the testicle (bell clapper deformity)
Outline the causes of epididymoorchitis
- Aetiology is from a variety of organisms
- males under 35 most common is gonococcus or chlamydia
- generally males over 35 it is due to obstructive urological disease
- ascending infection from urethra or prostate
- can be from Amiodarone and mumps
Outline the clinical manifestations of acute urinary retention
- lower abdominal pain
- complete or partial urinary retention
- overflow incontinence
- bladder distension
- irritation with voiding
- distress
Outline the clinical manifestations of renal calculi
- flank pain radiating to groin
- constant, gnawing ache around 12th rib
- agitated
- nausea and vomiting
- pallor, cool clammy skin
Outline the clinical manifestations of paraphimosis
- Foreskin of penis becomes trapped behind the glans penis and cannot be reduced to it’s normal flaccid position
- If left retracted some of the foreskin tissue may become oedematous
Outline the clinical manifestations of priaprism
- Persistent painful erection not associated with sexual desire
- Pain increases with duration and with urinary obstruction and bladder distention
Outline the clinical manifestations of testicular torsion
- sudden onset of severe scrotal or abdominal pain
- no voiding symptoms
- patient may look pale and vomit
- testicle is tender and may ride higher in the scrotum
- testicular swelling and scrotal oedema may be present
Outline the clinical manifestations of epididymoorchitis
- depends on the underlying cause
- pain may be sudden or slow, scrotal swelling and tenderness that is relieve by elevating the testis
- spermatic cord usually tender and swollen
- history of STI or prostatism
- pyuria
Discuss the management of acute urinary retention
- bladder scan
- IDC
- determine cause
Discuss the management of renal calculi
- analgesia (opiods or NSAIDS)
- IV fluids
- pathology
- urinalysis
- CTKUB
- D/C education and follow up
- extracorporeal shock wave lithotripsy (ESWL)
- ureteroscopy for middle and distal ureteral stones
Discuss the management of paraphimosis
- manual manipulation (compressing glans and moving the foreskin back with aid of lubricant, cold compression and local anaesthetic)
- if this fails can be relieved with dorsal slit or circumcision
- may express oedma fluid
Discuss the management of priaprism
- History (confirm duration of erection, PHx, illicit drug use)
- aspiration
- medications (phenylephrine injected to corpus cavernosum)
- surgery
Discuss the management of testicular torsion
- surgical exploration
- Colour Doppler imaging
- If you think it’s torsion don’t delay surgery
Discuss the management of epididymoorchitis
- bed rest, analgesia and
- scrotal supports
- if cause is secondary to STI then appropriate ab’s chosen after urethral swabs
- Ceftriaxone (single dose) for gonorrhoea and 14/7 doxycycline
- Roxithromycin for chlamydia
- test for syphilis or HIV
Define acute and chronic renal failure
AKI
- A sudden, marked and generally reversible reduction in kidney function
- can lead to CKD and CVD and death
CKD
- Characterised by progressive and irreversible destruction of renal function that occurs over time.
- The renal system experiences ischemia, inflammation, fibrosis, sclerosis, and scarring
- Undamaged nephrons increase their work rate and progressively become sclerosed and diminish
- Characterised by >3 months of evidence of injury
Differentiate between the clinical manifestations of acute and chronic renal failure
Acute:
- jaundice
- arrhythmias
- abdo pain
- hypertension
Chronic:
- metabolic acidosis
- oedema
- hypertension
- fatigue
- pericarditis
Define the pre-renal cause of acute renal failure
- Inadequate renal blood flow
- Adaptive response to severe volume depletion and hypotension
- Prerenal causes account for approx 55-60% of all cases of AKI
Discuss the pathophysiology of rhabdomyolysis
- A syndrome which is the result of a direct skeletal muscle injury or due to a discrepancy between energy production and
energy consumption within the body. - It occurs as the end result of muscle cell breakdown with spillage of intracellular contents into the systemic circulation, including MYOGLOBIN (also elevated CK, K, Mg, PO4, uric acid).
- Usually results in Acute Renal Failure due to tubular obstruction
Discuss the causes of rhabdomyolysis
- Trauma
- Metabolic and Endocrine (DKA, thyroid storm, hypokalemia)
- Strenuous exercise
- Muscle ischaemia
- Drug or toxin ingestion
- Envenomation
- Temperature extremes
- Infection
- Status asthmaticus
- Thyroid storm
Discuss the clinical manifestations of rhabdomyolysis
- Muscle pain
- Dark discoloured urine (myoglobinuria)
- History of underlying cause (i.e. trauma, physical activity, seizures)
- Lethargy, confusion,
- Fever
- Tachycardia
- Nausea and Vomiting
- Decreased urine output
- Evidence of complications
Discuss treatment of rhabdomyolysis
- Goals:
Treat cause
Prevent real failure - Bedside
ECG (hyperkalaemia, hypocalcaemia arrhythmias) - Laboratory
Elevated CK > 5 times normal indicates rhabdomyolysis
- peaks 1-3 days post injury and then steady decline
- if >5000 then more than 50% chance of AKI - FBE
- U&E
- Coagulation profile
- Urine myoglobin
Describe the indications for emergency dialysis
- control of uraemic symptoms
- control of Na+ and H2O balance
- control of acid/base balance
- control of hyperkalaemia
- control of calcium/phosphate balance
- Cr>400ugmol/L (AKI)
- GFR<10mL (CKD)
State two (2) examples of patient presentations to the ED that may cause rhabdomyolysis
- Trauma
- Metabolic and Endocrine (DKA, thyroid storm, hypokalemia)
- Strenuous exercise
- Muscle ischaemia
- Drug or toxin ingestion
- Envenomation
- Temperature extremes
- Infection
- Status asthmaticus
- Thyroid storm
Explain why volume replacement is important in the treatment of rhabdomyolysis
- hypoperfusion and hypovolaemia as fluid shifts from intravascular space into interstitial space
- If kidneys are hypoperfused AKI will occur and only be worsened by the lack of fluid volum
Define the intra-renal cause of acute renal failure
Characterised by acute tubular necrosis due to prolonged renal ischaemia, thrombotic disorders or nephrotoxic injury
Define the post-renal cause of acute renal failure
Mechanical obstruction of tubular or lower tract flow (urine is made but cannot get out) accounts for less than 5% of cases as it is usually treatable before it gets to that stage
