renal tract Flashcards
what is UTI and what are the different types?
bacteria in urine
asymptomatic or symptomatic
lower UTI - bladder = cystitis, prostate = prostatitis
upper UTI - renal pelvis/kidney = pyelonephritis
complicated = abnormal renal/GU tract, voiding, difficulty/obstruction or uncomplicated = normal renal tract and function
causes of complicated UTI
stones, obstruction, polycystic kidneys, vesicoureteric reflux
or associated disease - diabetes mellitus, sickle cell disease, analgesic abuse
= risk of kidney damage and septicaemia
who gets UTIs
more common women
>65 women, 20% have asymptomatic bacteriuria
new born males -GU abnormalities
teenage women - sexual activity
men when older = prostate problems
women post menopause = hormones
most common organism causing UTI
e.coli proteus mirabilis staphylococcus saprophyticus or epidermis enterococcus faecalis klebsiella aerogenes
recurrent UTI definition
and what can cause
same bacteria within 7 days of completion of antibacterial treatment
think stones, scarred kidneys, polycystic disease, bacterial prostatitis
reinfection UTI definition and what can cause
bacteriuria absent after treatment for 14 days, followed by reccurance of infection with same or different organism
implies reinvasion of susceptible tract with organism
risk factors of UTI
increased bacterial unoculation - sexual activity, urinary incontinence, faecal incontinence, constipation, female
increased binding of uropathogenic bacteria - spermicide, decreased oestrogen
decreased urine flow - dehydration, obstructed urinary tract
increased bacterial growth - DM, immunosuppression, obstruction, stones, catheter, renal tract malformation, pregnancy
presentation of cystitis
frequency dysuria urgency suprapubic pain polyuria haematuria
presentation of prostatitis
pain - perineum, rectum, scrotum, penis, bladder, lower back fever malaise urinary symptoms swollen or tender prostate on PR
examination signs of UTI
pyrexial abdo/loin tenderness foul-smelling urine distended bladder enlarged prostate
investigations for UTI
urine dipstick
urine MC+S - if symptomatic, dipstick positive, male, child, pregnant, immunosuppressed
blood tests - FBC, UEs, CRP and blood cultures if systemically unwell
imaging - utrasound, CTKUB, cystoscopy, MRI
treatment of UTI
drink plenty of fluids
urinate often
treat empirically with antibiotics until MC+S = trimethoprim or nitrofurantoin
prevention: drinking plenty, cranberry juice/tablets, antibiotic prophylaxis (continuous or post intercourse, self treatment when symptoms start)
how long to take antibiotics for UTI
non pregnant women = 3 days or 5-10 days if complicated infection
7 days for men
7 days in pregnant women
causes of pyelonephritis
bacteria ascending from lower UTI
risk factors for pyelonephritis
female
pregnant women
urinary tract blockage - kidney stones, enlarged prostate
weakened immune system - diabetes, HIV, certain meds
damage to nerves around bladder
urinary catheter
vesicoureteral reflux
presentation of pyelonephritis
proven UTI who has loin pain and/or fever
symptoms - fever, chills, flank or groin pain, abdo pain, freq, urg, dysuria, N+V, haematuria, foul smelling urine, rigors, septic shock
signs on examination of pyelonephritis
no clinical features that distinguish from cystitis
complications - kdiney scarring, septicaemia, pregnancy complications
investigations of pyelonephritis
MSU for culture and sensitivity
dipstick test
USS, CT scan or xray voiding cystourethrogram
treatment of pyelonephritis
prevention: fluids, urinate as soon as need to, wee after intercourse, wipe front to back, avoid feminine products
treatment:
- antibiotics for kidney infections - amoxicillin until sensitivity testing.
IV antibiotics and fluids if hospitalised
recurrent - may be due to misshapen urinary tract = need surgery to repair structural abnormality
what is hydronephrosis
swelling of one or both kidneys when urine cannot drain
occurs due to blockage of ureters or anatomical defects
causes of hydronephrosis
most common: prostatic obstruction, gynaecological cancer, calculi
split into intralumenal obstruction or obstruction within the wall (congenital abnormalities of urinary tract, stricture, neuropathic bladder)
presentation of hydronephrosis
loin pain that radiates to lower abdo or groin
dysuria, urgency, frequency
nausea and vomiting
fever
failure to thrive in infants
signs on examination of hydronephrosis
depends on sight of obstruction
enlarged bladder or hydronephrotic kidney felt on exmamination
pelvic and rectal examination to determine cause of obstruction
investigations for hydronephrosis
imaging - USS, excretion urography
radionuclide studies - differentiated long standing obstruction
bloods - creatinine and function of kidneys
urine dipstick/MCS - identify stones/infection which may be cause of blockage
treatment of hydronephrosis
mild to mod = wait and see approach, preventative antibiotic therapy to lower risk of UTI
severe - surgery if affects kidney function to fix blockage or correct reflux
types of acute kidney injury
pre renal
renal
post renal
causes of pre renal acute kidney injury
hypovolaemia
hypotension
impaired cardiac pump efficiency
vascular disease limiting renal blood flow
risk factors for acute kidney injury
> 65
history of AKI
chronic kidney disease eGFR<60
symptoms of urological obstruction or conditons which may lead to this
chronic conditions - liver, heart, diabetes
neurological or cognitive impairment or disability
sepsis
hypovolaemia
oliguria
nephrotoxic drug use within last week
exposure to iodinated contrast agents within last week
signs on examination of AKI
nausea, vomiting, drowsiness, breathlessness (pulomnary oedema or metaoblic acidosis)
arrhythmias
hyperkalaemia
metabolic acidosis
hyponatraemia
hypoglycaemia (reduced vit D) and hyperphsophataemia (phosphate retention)
investigations of pre renal AKI
tests to differentiate between pre renal and intrinsic causes
- urine specific gravity and urine osmalarity
- urine sodium
- fractional excretion of sdium
treatment of pre renal AKI
prompt fluid replacement (blood in case of haemorrhagic shock or crystalloid in vomiting, diarrhoea, polyuria)
treat underlying cause e.g. if related to cardiac pump insifficiency or occlusion of renal vasculature
intrinsic AKI causes
acute tubular necrosis as result of renal ischaemia or direct renal toxins
disease affecting the interstitium, renal vasculature, acute glomerulonephritis
causes of acute tubular necrosis
haemorrhage burns diarrhoea and vomiting fluid loss from fistula acute pancreatitis diuretics MI congestive cardiac failure endotoxic shock myoglobinaemia haemoglobinaemia hepatorenal syndrome radiological contrast agents drugs - aminoglycosides, NSAIDs, ACEi, platinum derivatives, abruptio placentae pre-eclampsia, eclampsia
presentation of AKI
risk facotrs, urological symptoms, multi system disease affecting kidneys
alteration of urine volume
biochemical abnormalities
investigations of intrinsic AKI
blood count
urine and blood cultures
urine dipstick testing and microscopy
histological investigations
treatment of intrinsic AKI
fluid correction
sodium and potassium restricted
stop nephrotoxic drug and adjust doses of others
causes of post renal AKI
occurs when both urine outflow tracts are obstructed or when tract is obstructed in paitent with a single functioning kidney
quickly reversed if obstruction releived
investigations of post renal AKI
renal ultrasonohraphy for hydronephrosis and dilated ureters
bladder outflow obstructed ruled out by flushing of existing catheter or insertion of urethral catheter - removed unless larged vol of urine obtained
treatment of post renal AKI
temporary measures to relieve fluid build up - urethral/suprapubic catheterisation or percutaneous nephrostomy until definitive treatment of obstructing lesion can be undertaken
what is chronic renal failure
abnormal kidney structure or function present for >3 months with implications for health
classification is based on GFR category, presence of albuminuria as a marker of kidney damage and the cause of kidney disease
who gets chronic renal failure
older ppl
more in females
causes of chronic renal failure
intrinsic kidney disease - associated conditons: hypertension, DM
nephrotoxic drugs - lithium, ciclosporin, calcinuerin inhibitors, aminoglycosides, mesalazine
obstructive kidney disease - assoicated conditions: neurogenic bladder, BPH, urinary division surgery, recurrent urinary stones
Multisystem disease: SLE, vascultitis, myeloma, AD polycystic kidney disease, alports disease, familial glomerulonephritis, DM, polycystic kidney disease
acute renal failure
risk factors of chronic kidney disease
AKI CVD hypertension or proteinuria diabetes smoking NSAIDs - chronic use nephrotoxic drugs untreated urinary outflow obstruction SLE
presentation of chronic kidney disease
anaemia
platelet abnormalities
skin pigmentation pruritis
GI - anorexia, nausea, vomiting, diarrhoea
endocrine/gonads - ammennhoria, erectile dysfunction, infertility
polyneuropathy
CNS- coma, confusion
CVS - uraemic pericarditis, hypertension, peripheral vascular disease, heart failure
renal - nocturia, poluria, salt and water retention, oedema
renal osteodystrophy - osteomalacia, muscle weakness, bone pain, hyperparathyroidism, osteosclerosis, dynamic bone disease
investigations for chronic kidney disease
serum creatinine urine electrolytes blood count urine and blood cultures urine dipstick and microscopy histological investigations
who gets BPH
elderly men >60
causes of BPH
hyperplasia of both glandular and connective tissue elements
aetiology unknown
risk factors of BPH
age,
metabolic syndrome,
presentation of BPH
increased frequency of micturition
nocturia
delay in initiation of micturition and post void dribbling
acute urinary retention or retention with overflow incontinence also occurs
signs on examination of BPH
enlarged smooth prostate
investigations of BPH
serum electrolytes and renal ultrasonography to exclude renal damage resulting from obstruction
prostate cancer present with similar symptoms
serum PSA elevated in benign disease but elevated value is usually an indication for specialist referral and prostate biopsy
treatment of BPH
if mild symptoms - watchful waiting
selective a1-adrenoreceptor antagonists such as tamsulosin = relax smooth muscle in bladder neck and prostate producing increase in urinary flow rate and improvement in obstructive symptoms
5a reductase inhbiitor finasteride = prevents further enlargement
acute retention or retention with overflow = urethral catheterisation or if not possible suprapubic catheter drainage
prostatectomy or permanent catheter as later treatment options
who gets prostate cancer
most common cancer in men
malignant change within prostate increasingly common with age
causes of prostate cancer
ethical
familial and genetic risk factors
- genetic mutations of androgen receptors of prostatic cells = hormone treatment effective
risk factors for prostate cancer
increasing age
ethnicity - black African or black Carribean
family history
BRACA gene mutation
signs on examination of prostate cancer
hard irregular gland
investigation of prostate cancer
transrectal US of prostate
elevated serum PSA
transrectal prostate biopsy
if mets are present, PSA usually markedly elevated
endorectal coil MRI used to locally stage tumour
treatment of prostate cancer
microscopic tumour usually by watchful waiting
treatment of disease confined to gland is radical prostatectomy, radiotherapy = 80-90% 5 yr survival
treatment of metastatic disease depends on removing androgenic drive to the tumour - bilateral orchiectomy (testes) , synthetic luteinising hormone releasing hormone analogues
who gets bladder carcinoma?
M:F 3:1
5th commonest cause of cancer deaths
risk factors for bladder caricnoma
exposure to aromatic hydrocarbons - industrial workers, chimney sweep
smoking
presentation of bladder carcinoma
painless haematuria
painless micturition
renal colic due tot blood clot, disturbance of urinary stream, retention of urine
investigations of bladder carcinoma
urine cytology - malignant cells
cystoscopy also possible
treatment of bladder caricnoma
transurethral resection
TCT an be completed by endoscopic resection
intravesical chemo reduces high risk of occurrence
may need radical cystectomy
who gets renal carcinoma
M:F 3:1
location of renal carcinoma
often small and can be multiple
local spread often includes spread via intravascular invasion to the renal vein and IVC
risk factors for renal carcinoma
FHx
clinical evidence of neurological or ocular disease should raise possiblity of von hippel lindau disease
presentation of renal carcinoma
may be asymptomatic
tumour detected during imaging of abdomen for unrelated conditon
painless haematuria, groin pain, awareness of mass arising from the flank, chest symptoms and bone pain present to these sites
investigations for renal caricnoma
blood tests and ferritin to check for anaemia
electrolytes and creatinine to check overall renal function
raised corrected calcium and alkaline phosphatase suggest bony mets
diagnostic staging and diagnosis by CT with contrast
isotope bone scan if clinical or biochemical evidence of bony mets
treatment of renal carcinoma
surgery - only curative treatment except in very elderly, extensive local invasion and mets - partial or radical nephrectomy depending on size
medical therapy - used for metastatic disease. biological therapy with immune modulators (interferons and interleukins). chemo not used as renal cancers arent usually sensitive
radiotherapy for palliative painful bone mets
who gets urinary tract stones
males >females
20-50 yos
causes of urinary tract stones
metabolic - hyperparathyroidism, idiopathic hyperclaciuria, disseminated malignancy, sarcoidosis, hypervitaminosis D
familial metabolic causes - cysturia, errors of purine metabolism
infection
impaired urinary drainage - medullary sponge kidney, pelvi-uteric junction obstruction, ureteric stricture, extrinsic obstruction
risk factors for urinary tract stones
summer months
most are calcium stones
presentation of urinary tract stones
ureteric/renal colic
severe intermittent stabbing pain radiating from loin to groin
microscopic or rarely, frank haematuria
systemic symptoms such as nausea, vomiting, tachycardia, pyrexia
loin or renal angle tenderness due to infection or inflammation
iliac fossa tenderness if passed to distal ureter
investigations of urinary tract stones
raised WCC and CRP suggest infection and inflammation
raised Cr = renal impairment
stones often visible on plain abdo Xray. gold standard is non contrast CT
serum calcium, phosphate and uric acid
treatment of urinary tract stones
acute presentation - analgesia, if <0.5cm then conservative treatment
percutaneous nephrostomy or uteric stent insertion if painful or obstruction persistent
elective presentation - extra-corpeal nephrolithotomy, endoscopic treatment or open nephrolithotomy
