Renal / urology Flashcards
What are red flag features for haematuria that warrant immediate Imaging and referral?
(6)
age > 50
smoking history
Risky occupational exposure for example benzenes
History of gross/macroscopic haematuria (unless <40 and thought to be transient or UTI) .
prior pelvic radiotherapy
recurrent UTIs
Briefly describe the two mechanisms behind urinary Urge Incontinence.
- Overactive bladder. The detrusor muscle (muscular wall of the urinary bladder) over contracts, can be due to irritation from the epithelial or sensitivity of the detrusor itself. May also be due to denervation in diseases like parkinsons–> loss of inhibitory neurons.
- Low compliance. Lack of ability of the bladder wall to stretch and hence accomodate more urine. Usually due to a fibrotic disease process.
When asking about urinary issues, what categories of questions do you want to cover.
(3)
- Storage issues:
-incontinence; urge, stress
- nocturia - Voiding issues
Hesititancy, stream strength, interrupted stream, straining, dribbling, incomplete emptying - Exacerbating factors
5 D’s
Times of Day
Diuretics
Diabetes
Fluid intake (Drinking)
Urinary Tact infection (?Disease –that’s a long shot)
Tests to investigate urinary or voiding symptoms?
(3)
(4)
Bladder Diary
U/S Bladder +/- post void volumes
Urine MCS
Other:
Urinanalysis
Urine casts, and Crystals
Urine red cell morphology (if haematuria)
Urine cytology (if suspicious of cancers)
Management for stress incontinence. Give specifics
- Weight loss 5-10% of current body weight
- Pelvic Floor exercises: sets of 8-12, held for 6-8 seconds done 3-4 times a week for 3-4 months.
(only after a strict regime followed for 3-4 months, can you deem failure)
- Surgical/procedural
Surgical: bladder sling to reduce bladder neck hypermobility
Periurethral bulking agents
Medication for Urinary Urge incontinence?
Oxybutynin 2.5-5mg orally, 2-4 times a day
or
Solifenacin (vesicare) 5mg orally, daily.
Other treatment for urinary urge incontinence (not medical)
weight loss
bladder training
relaxation and distraction techniques
Causes of CKD?
up to 9 answers
list the main 4
- Type 1 and 2 Diabetes*
- Hypertension*
- Polycystic Kidneys*
- Interstitial nephritis
- Other inherited diseases
- Prolonged obstruction of the urinary tract
- Glomerulonephritis*
- Reflux (vesicouretal disease)
- recurrent pyelonephritis.
Who should be screened for CKD?
(8)
ABTI
> 60
HTN
T2/T2DM
Fx kidney disease
Heart disease
Obese BMI>30
Smoker
What is needed for the diagnosis for CKD and albuminurea stage?
- need three reduced eGFRs in >3 months.
usually 1 then repeat in 1 week then again at some point
2.In => 3months you need 2 out of 3 ACRs to be >2.5 or >3.5 to count as albuminuria
What Investigations to order after diagnosis of renal disease?
Apart from the repeat tests (eGFR and ACR),
Renal U/S
FBE,
CRP/ESR
Fasting lipids and FBG (if not already done)
Urine microscopy for red cell morphology, casts or crystals
MIGHT need
vasculitis screens: ANA, ENA
connective tissue autoimmune screens: ANA, RF,
if >40 with bone pains or weight loss and raised ESR, consider testing for Multiple Myeloma
Nutrition, Weight loss and hypertension advice in CKD?
(3)
(2)
(1)
Limit salt < 4grams a day
Protein no less than 0.75mg/kg per day
Reduce saturated and trans fats
Weight loss to target BMI 18- 25 or WC < 94/90 in men/asian men, WC < 90/84 in women/asian women
BP goals <130/80
For moderate - severe (orange and red) CKD, apart from the basic
EUC, with eGFR, ACR, HBA1c and lipids what other tests would you order
FBC
PTH (6-12 monthly)
Calcium+ Phosphate
When to refer to a nephrologist for CKD?
(4)
eGFR < 30
Persistent significant albuminuria ACR>30
A sustained decrease in eGFR of >25% within 12 months
or reducing by 15ml/min/kg a year
CKD with HTN on three agents and not controlled
What is the positive predictive value of haematuria for malignancy?
11%
that is high
What are risk factors for urothelial malignancy when approaching a presentation for haematuria?
Age > 50
Smoking History
Occupational exposures (dyes, benzines, aromatic amines)
History of GROSS haematuria
Pelvic radiotherapy
Recurrent UTIs
What imaging is preferred for investigating haematuria, and when should this be done?
CT pyelogram preferred
otherwise CT KUB
OR renal tract U/S
Do for gross haematuria
Also for anyone with risk factors (> 50, smoking, occupational exposure, pelvic irriadiation)
First line investigations for haematuria?
(3)
(2)
Urinanalysis
Urine MCS
Casts and cells (if features of renal disease, otherwise can wait until repeat)
CT KUB if high risk
Urine cytology if high risk
If a patient is confirmed or highly suspicious to have renal calculi, under what circumstances should they go straight to the E.D?
(4)
Single kidney
Bilateral stones (after imaging)
End stage renal failure
Signs of UTI or sepsis
What size stone is the cut off for managing conservatively?
7mm
What is the management for a renal stone <7mm?
Conservative
- analgesia
NSAIDS, paracetamol and in this case opioids IF needed - Strain for stone
- CT KUB (repeat) 4 weeks later
What are 3 aspects of management of a renal stone >7mm?
Refer to urology for correction
Keep hydrated to prevent AKI
Analgesia
Most renal calculi/ stones are composed of calcium oxalate.
What 3 dietary recommendations can be followed?
lower sodium diets (as low sodium can cause reduced calcium excretion)
lower oxalate diets (chocolate, berries)
Don’t have a high protein diet (as this causes acidic urine which is associated with stone formation. this can be achieved by using a vegetarian diet)
What can be done for conservative management of a urinary stone?
Actions and advice
(6)
- Appropriate NSAID script
- Provide a prescription for tamsulosin 400mcg orally daily
- Appropriate antiemetic script. ondansetron 4mg orally every 8 hours as needed
- Advise patient to check urine at home for whether the stone passes spontaneously
- Advise to collect any passed urinary tract stones in a specimen jar so that it can be sent to pathology for analysis
- Provide appropriate advice for when to re- present to the emergency department (one example accepted, e.g. any signs of a urinary tract infection, uncontrolled pain)
