Renal Medicine 3

Question 1

what is included in urinary tract disease

Answer 1

• Urinary tract infection
• Urinary tract obstruction
	○ Renal stones
	○ Tumours 
	○ Prostatic hypertrophy
• Urinary tract malignancy

Question 2

who is urinary tract infection more common in

Answer 2

more common in women than men

Question 3

what are the usual micro-organism causing UTIs

Answer 3

• Usually E.coli (85%)
○ Staph, fungi, virus & TB possible

§ An immunosuppressed individual is more likely to have other organisms getting in
Urine bacteriostatic to perineal organisms

Question 4

what is cystitis

Answer 4

bladder inflammation

Question 5

what are predisposing factors to UTIs

Answer 5

○ Poor bladder emptying

○ Low urinary flow rate

Question 6

is there bacteria in urine normally

Answer 6

no
urine is sterile
detecting any bacteria implies infection

Question 7

is it normal to find cells in the urine

Answer 7

no
white cells in the urine is indicative of UTI
blood (red cells) and proteins should also not be found in the urine

Question 8

which section of the urine is the most sterile

Answer 8

• Collect MID-stream urine sample (MSSU)
○ Middle section of urine is the most sterile
○ Start of urine is washing out bacteria trying to ascend
○ End of urine there is a risk of organisms trying to get in again

Question 9

what does urine sampling show and include

Answer 9

• Shows how contamination changes with flow
• Usually the mid stream is the least contaminated
• Random sampling more likely to catch contamination

Question 10

what is supra-pubic urine sampling

Answer 10

• Needle into abdomen and penetrates the bladder to take a sample out
• Can have a catheter at the bottom of the abdomen
  ○ Less inconvenient having it in your stomach
  ○ Less likely to get infected
  ○ Patients are still free to pee
  ○ Better long term

Question 11

what can infected urine cause

Answer 11

○ Cystitis
§ Can spread upwards to the kidney - more likely when you have problems with urine flow
§ Muscle of bladder can contract incorrectly
□ When it contracts it should close off access to the ureters so the urine cannot go back to the kidney
□ When this isn’t working then the urine can be squeezed back up to the kidney and any micro-organism in it can reach the kidney

○ Renal infection

○ Prostate infection
§ Urine passing through the prostate gland
Antibiotics into the prostate area can be difficult

Question 12

does urethritis always come with cystitis

Answer 12

no
urethritis can happen in isolation
does not spread into the bladder usually

gonococcal - tends to be more localised

Question 13

what is urine reflux

Answer 13

• Bladder contracts (during voiding) and instead of forcing urine out of the urethra as normal it also forces urine back into the kidneys
• UTI can be passed up into the kidneys and can a renal infection
• Can be an inherited problem
  ○ Some people are born this way
• Can be a developed problems

Usually need surgery to get the ureter to properly close off during voiding when the bladder contract

Question 14

what are the symptoms of an UTI

Answer 14

• Dysuria = Pain on peeing

• Urinary frequency
○ Need to pee more quickly = lots of voiding
○ Takes less filling before it needs to empty
○ Doesn’t pass as much urine each time you pee as the bladder isn’t full

• Cloudy urine (should be clear)
○ Infected urine contains cells and proteins which creates the cloudy appearance

• Offensive smelling urine

• Supra-pubic pain
○ The bladder sits relatively close to the pubic bone
○ Causes pain in abdomen

• Symptoms vary for patients

Question 15

how is a UTI diangosed

Answer 15

○ MSSU only (less contamination)

○ Microscopy, culture and sensitivity
§ Look for cells in the urine 
§ Try to culture the organism
□ Most of time will be E.coli
From this the lab will try and see what drugs the organism will be sensitive to

Question 16

how is a UTI treated

Answer 16

• Increase fluid intake

• Frequent micturition
○ Pee more

• Occasionally antibiotics are required
○ Trimethoprim, amoxycillin
§ Don’t need to have an antibiotic for a UTI unless things have gone too far and the infection has spread systemically and the patient has a fever etc

§ If you think you have a UTI starting then just increase fluid intake to try and wash out the infection by peeing more often

Question 17

what causes urinary tract obstructions

Answer 17

• Renal calculi / stones

• Prostatic disease
○ Hypertrophy
○ Prostatic malignancy

• Urinary tract strictures

• External compression
○ Squishing the urinary tracts

Question 18

where do kidney stones have the worst effect

Answer 18

ureter
causes ureter muscle to spasm as it tries to pass the stone

once it reaches the bladder it can usually pass fairly painlessly

Question 19

describe kidney stones

Answer 19

§ Stones form in the pelvis of the kidneys

□ Can be sharp and pointy and different sizes

® Big stones usually remain in the kidney

® Small stones can usually pass with little problem

® It is the middle stones that cause the worst pain as they are small enough to move but still big enough to get caught

Question 20

where can the prostate gland be found

Answer 20

Prostate gland sits just underneath the bladder and urine has to pass through this to get out of the body

prostate gland grows throughout life

Question 21

what is prostatitis

Answer 21

○ Inflammation of the prostate
○ Causes sudden narrowing of the urinary passage
○ Can happen within days or hours

• causes discomfort when patient tries to pee and urine flow is more difficult
• usually bladder struggles to maintain the pressure needed to force urine out of the body so results in incomplete emptying of the bladder = risk of a UTI

Question 22

what is benign prostatic hypertrophy

Answer 22

○ Hyperplasia of the prostate
§ Not linked to prostatic cancer

○ Happens over a longer period - usually over years

○ Can completely block urinary outflow
More people have this

gland gets bigger and causes the urethra to narrow
not due to inflammation

tends to affect the full gland

Question 23

what is prostatic cancer

Answer 23

○ Adenocarcinoma

○ Not linked to benign prostatic hypertrophy

○ Happens in one area with the prostate and as it gets bigger it can stop the urinary outflow

Question 24

how can you deal with the effects of prostatitis

Answer 24

make the urethra bigger

Question 25

is benign prostatic hyperplasia common

Answer 25

Almost normal
○ 80% men over age of 80 have benign prostatic hypertrophy
○ 100% if they live long enough

Common in older men - over 50s especially

Question 26

what are the symptoms of urine outflow obstruction

Answer 26

○ Slow stream = Difficulty passing
○ Hesitancy = Kind of like Parkinson’s disease of the bladder
○ Frequency = Smaller volumes of urine more often
○ Urgency = When you need to pee you need to pee
○ Nocturia = Wakens you during the night as you will need to pee
○ Incomplete voiding

Question 27

what is the treatment for urinary outflow obstruction

Answer 27

○ Initially drug based
§ Alpha-blocking drugs
§ Can make the gland shrink - if these drugs work then the symptoms of the obstruction tend to go away
§ This works for a while but will ultimately need surgery for the full problem to settle
□ Helpful for a few years

○ Surgery - prostatectomy
§ TURP - transurethral proctectomy
§ Open prostatectomy
□ Taking the whole prostate gland out

Question 28

what are the problems associated with prostatectomy

Answer 28

® Tricky to access - sits at bottom of pelvis near important parts

® Get the operation wrong and can damage the bladder and the bladder sphincters and leave the bladder incompetent

however Good for some people as if there are more tumours within the prostate gland then they are removed also

Question 29

what does transurethral prosectomy

Answer 29

• Like using an apple corer and putting the tube in to cut away the gland
  ○ Chop off bits of the prostate gland
  ○ Can get incompetence
  § Can be helpful or end badly if damages bladder
• Can get enough capacity in the tube for the urine to flow better

Question 30

what are the biggest problems with prostatic malignancy

Answer 30

> affects a lot of men

• starts after age 45
• 90% of over 90s have this
• 2nd commonest male cancer

> most asymptomatic
- only 10% will have symptoms

> not easily detected

• no good way to screen
• cannot vaccinate against

Question 31

is a PSA blood test diagnositc

Answer 31

= Prostatic specific antigen

○ Problems with specificity and sensitivity excludes using PSA for screening
§ Can be normal when you do have the cancer
§ Can be high when you don’t have the cancer
§ Not reliable

Useful for monitoring disease activity if it is know the patient has the disease

Question 32

what is the best way of looking for prostate cancer

Answer 32

MRI scan

Question 33

how is prostatic malignancy treated

Answer 33

○ Surgery - radical prostatectomy
§ First thing is to get rid of the gland
§ Can lead to incompetence problems

○ Radiotherapy
§ Can slow down the cancer

○ Hormone treatment
§ Anti-androgens and LHRH analogues
§ Block hormone dependent tumour growth
§ Gland related tumours are usually associated with hormone levels (can help the tumours to grow)
Testosterone makes the gland / tumour grow then give drugs to block the testosterone release and mimic changing the gender (oestrogen) on a low level to slow down the progression

Question 34

what can prostate malignancy cause

Answer 34

• Widespread bone metastasis
○ Osteosclerosis
§ Likes to spread in bones
§ Usually have bone condensing (becomes more dense) or forming around tumour cells

Question 35

what are the different stone types in renal calculi

Answer 35

Calcium and oxalate (radiopaque)

Uric acid (not radiopaque)

Question 36

how is renal calculi treated

Answer 36

not causing problems then usually no treatment is needed

if causing a problem = lithotripsy
= breaks the kidney stones into small bits using ultrasound energy from outside the body (uses the same principles as ultrasonic scalers)