Urinary Flashcards
Name 4 symptoms and signs of upper urinary tract obstruction
- loin to groin /flank pain on affected side due to stretching and irritation of ureter and kidney
- reduced or no urine output
- nonspecific symptoms eg vomiting
- impaired renal function on bloods (raised creatinine )
Name 3 symptoms of lower urinary tract obstruction
- Difficulty / inability to pass urine eg poor flow, difficulty initiating urination, terminal dribbling.
- urinary retention with increasingly full bladder
- impaired renal function on bloods ie raised creatinine
Name 6 common causes upper urinary tract obstruction
. Kidney stones
. Tumours pressing on ureters
• ureter strictures (due to scar tissue narrowing the tube)
• retroperitoneal fibrosis ( development of scar tissue in retroperitoneal space)
• bladder cancer blocking ureteral openings to bladder
• ureterocoele - ballooning most distal portion ureter, usually congenital
Name 5 common causes lower urinary tract obstruction
• Benign prostatic hyperplasia . Prostate cancer . Bladder cancer (blocking neck of bladder) • urethral strictures due to scar tissue • neurogenic bladder
Name 7 complications obstructive uropathy
- Pain
- AKI post-renal
- CKD
- infection from bacteria tracking up urinary tract into areas of stagnated urine
- hydronephroses - swelling of renal pelvis and calyces in kidney
- urinary retention and bladder distention
- overflow incontinence of urine
What is Desmopressin used for?
Enuresis
! Define enuresis
Persistence of involuntary voiding of urine beyond age of anticipated control ie bedwetting > 2 times per month in child ≥5
Classification enuresis?
- Primary: child has never successfully controlled urination
- secondary: recurrence of incontinence after being dry for > 6 months. Usually in response to some sort of stressful situation
Name 7 causes nocturnal enuresis
• vast majority no physical or mental abnormality!
• sleep disorders!: deep sleepers, disorder of arousal, OSA
• nocturnal polyuria!: due to decreased ADH.
• decreased functional bladder capacity!
• developmental delay of CNS
• genetic factors
• Psychology. Eg anxiety
. Bladder detrusor/sphincter dysfunction.
Name 9 causes enuresis in adults
- Bladder cancer
- diabetes
- medication side effects eg tricyclic antidepressants, alpha blockers in females
- neurological disorders eg spinal cord injury, meningomyelocele, cerebrovascular accident, Parkinson’s etc
- OSA
- prostate cancer
- prostate enlargement
- UTI
- ut stones
Define diurnal enuresis
Daytime accidental wetting in children
Name 4 causes diurnal enuresis in children
- Overactive bladder
- inadequate voiding
- small bladder capacity
- constipation
Which special examinations can be performed for enuresis? (3)
- Nb if monosymptomatic enuresis (nocturnal wetting with no other urinary symptoms) with normal examination and normal urinalysis, no special investigation indicated!
- If UTI: do ultrasound and indirect cystogram (to exclude vesico-ureteric reflux)
- If day time symptoms or suspect neuropathic bladder: ultrasound. If trabeculated bladder and or hydronephrosis, do MCUG and UDS (urodynamic studies)
Treatment enuresis? (6)
First line = lifestyle
• fluid restrict before bedtime,
• walking child at night to void,
. bladder diary to monitor progress and diagnose nocturnal polyuria.
• star charts
• conditioning therapy by enuresis alarm most effective! To inhibit micturition reflex, take a month
Second line = pharmacotherapy
• not recommended before age 7
• desmopressin preferred (vasopressin- ADH analogue to decrease urine output)
• imipramine (TCA): lighten sleep level, anticholinergic on bladder, alpha-adrenergic on bladder neck
• anticholinergics: oxybutinin-only for day time symptoms
Name 7 causes pseudohaematuria
• vaginal bleeding
• dyes: beets, rhodamine B in candy and juices
• haemoglobin (haemolytic anemia )
• myoglobin (rhabdomyolysis)
• drugs (rifampin, phenazopyridine, phenytoin)
• porphyria
. Laxatives (phenolphthalein)
Name 6 infections / inflammatory causes haematuria
- Pyelonephritis
- Tb
- cystitis
- schistosomiasis
- urethritis
- glomerulonephritis (especially IgA nephropathy )
- interstitial nephritis
Name 6 malignant causes haematuria
• renal cell carcinoma (adults)
• wilms’ tumour (paeds)
• urothelial cancer - ureter tumour, bladder cancer (most common cause painless macroscopic haematuria in older patient! ), urethra carcinoma
• prostate cancer
• leukemia.
!Haematuria = bladder cancer until proven other wise!
Name 3 benign causes haematuria
. BPH
• polyps
• exercise induced
Name 9 structural causes haematuria
- Stones (renal, ureter, bladder )
- Trauma eg catheter, TURP, TRUS,,
- foreign body
- urethral stricture
- polycystic kidneys
- vascular kidneys: renal vein thrombosis, arteriovenous fistula
- infarct
- hydronephrosis
- fistula
Name 4 haematologic causes haematuria
• Anticoagulants eg warfarin • coagulation defects eg haemophilia • sickle cell disease . Leukemia • thromboembolism
Why is the relationship between micturition and bleeding important in haematuria?
- Initial haematuria: blood visible at beginning of micturition, then clears. Origin = urethra, especially prostatic
- total haematuria: origin = upper tracts or bladder
- terminal: origin= bladder or prostate. Classical presentation schistosomiasis (bilharzia) of bladder!
How can urological, haematological and nephrological causes of haematuria be differentiated on urinalysis? (3)
Nephrological
• 2-3+ proteinuria
• red cell casts or dysmorphic red cells on microscopy
Haematological and urological
• no proteinuria
• normal RBC
• no red cell casts, but white cell casts may be found in patient with acute pyelonephritis
Define haematuria
Passage of more than 3 RBCS/ HPF (high power field) on urine microscopy
Which investigations should be done in patients with haematuria? ( 7 )
- Kidney, ureter, bladder ultrasound on all patients!
- cystoscope in all patients! Except if low risk malignancy (<40, female, microscopic haematuria, non-smoker)
- early morning urines if suspect urinary Tb
- urine cytology if bladder or upper tract tumour suspected
- urine microscopy for ova if schistosomiasis (bilharzia) suspected
- CT scan if renal mass on ultrasound or suspected stone disease (renal colic symptoms )
- haematological tests if haematological cause suspected eg INR if on anticoagulants
How describe light coloured urine medically?
Serous urine
How describe dark coloured urine medically?
Sangiounous urine
Describe the steps of the act of micturition (6)
- Voluntary suppression of cerebral inhibition via cortical micturition centre in frontal cortex
- increased intra-abdominal pressure via contraction diaphragm, abdominal wall muscles and pelvic floor
- detrusor contraction by stimulation of efferent motor fibres (parasympathetic bladder centre s2-s4)
- increase intravesical pressure → opening bladder neck
- when intravesical pressure exceeds urethral pressure, distal sphincter mechanism opens and voiding occurs (inhibition sympathetic t11 - L2 and somatic pudendal nerve s2-s4)
- voluntary relaxation of pelvic floor and striated urethral sphincter
• when bladder empty: detrusor relax, bladder neck close, urethral and perineal muscle tone return to normal
Classification and etiologies neuropathic bladder? (5)
Failure to empty: lower motor neuron pathology at ( lesion below L1 )
• bladder centre spinal cord s2-s4 eg trauma
• efferent parasympathetic s2-s4 fibres eg gullain barre
• afferent. parasympathetic fibres eg diabetic autonomic neuropathy
• both efferent and efferent eg radical pelvic surgery
Failure to store: upper motor neuron lesion due to disease above bladder centre s2-s4 in spinal cord or cns (lesion above T12 )
Name 7 clinical features of LMN neuropathic bladder
• Overflow incontinence (failure to empty) • urinary difficulty • nocturnal enuresis • bladder palpable, non-tender • perianal sensation absent (S2-S4 affected) • anal tone decreased • bulbo-cavernosus reflex absent • constipation or fecal incontinence . ED
Name 4 clinical features of UMN neuropathic bladder with disease above brainstem
- Frequency and urgency (failure to store)
- urge incontinence
- bladder impalpable
- normal examination of s 2,3,4 reflex arc
Name 5 clinical features of UMN neuropathic bladder with suprasacral spinal lesion
- Completely incontinent (reflex voiding)
- bladder impalpable
- bulbocavernosus reflex brisk
- peri-anal sensation absent
- anal tone increased
- ED
- fecal incontinence
Which special investigations should be done for neurogenic bladder? (3)
• Renal function tests
• Ultrasound kidneys: rule out hydronephrosis (sign upper tract deterioration), stones (if found, do IVP/EUG)
• urodynamic studies!
- nb intravesical pressure: low pressure = safe bladder; high = unsafe (risk upper tract deterioration)
• MCUG: bladder capacity, wall smooth or trabeculated, exclude vUR
Name 7 complications neurogenic bladder
- Renal failure
- calculi renal and bladder
- recurrent UTI
- VUR
- urethral diverticulum and fistula due to long indwelling transurethral catheter
- Scc bladder if catheter >10 years
- autonomic dysreflexia: associated with injury above t6. Unopposed sympathetics. Bladder distension one of most common precipitating factors. Emergency, give iv nifedipine for bp
Treatment LMN neuropathic bladder?
Clean intermittent self-catheterisation (cisc) or indwelling catheter if not possible
Treatment UMN neuropathic bladder by CNS causes?
Anticholinergic’s eg oxybutinin, tolterodine
Treatment UMN neuropathic bladder by spinal causes? ( 5)
- CISC and anticholinergics eg oxybutinin, tolterodine
- if refractory: botulinum toxin inject into bladder wall and CISC
- external sphincterotomy to reduce outlet resistance and condom catheter
- augmentation cystoplasty (segment of ileum or colon used to enlarge bladder volume ) and CISC
- supravesical urinary diversion eg ileal conduit, continent diversion (last resort)
Name 5 goals of treatment of neuropathic bladder
• Upper tract preservation or improvement
• prevent or control UTI
• adequate emptying. at low intravesical pressure
• urinary continent
.No indwelling catheter or stoma
Name 5 hereditary risk factors urolithiasis
•Rta (renal tubular acidosis) • g6pd (glucose 6 phosphate dehydrogenase) deficiency • cystinuria (stones from cysteine AA ) • xanthinuria • oxaluria Etc
Name 5 lifestyle risk factors urolithiasis
- Minimal fluid intake
- excess vitamin C
- excess oxalate (spinach, beetroot, sweet potato, soy, almonds)
- excess purines (alcohol, anchovies and sardines, bacon, liver, raisins)
- excess calcium ( dairy, broccoli, soybeans, )
Name 4 medication risk factors urolithiasis
- Loop diuretics: furosemide, bumetadine
- acetazolamide (carbonic anhydrase inhibitor, lower blood ph)
- topirimate
- zonisamide (sulphonamide for epilepsy)
Name 7 medical condition risk factors urolithiasis
• UTI with urea-splitting organisms: proteus, pseudomonas, providencia, klebsiella, mycoplasma, serratia, S aureus
• myeloproliferative disorders
• IBD
• gout
• dm
. Hypercalcaemia disorders: hyperparathyroid, tumour lysis syndrome, sarcoidosis, histoplasmosis
• obesity BMI >30
Etiology and classification bladder calculus? (7)
Primary (endemic): usually children, associated with malnutrition and recurrent gastroenteritis (dehydration)
Secondary
• bladder outflow obstruction!
• Foreign bodies
- “egg shell” encrustations following indwelling catheters
- non-absorbable sutures eg colposuspension
-Inserted into urethra by patient
• stasis and infection
- Neuropathic bladder
-Bladder diverticulum
• stone from upper tract
• metabolic: primary hyperparathyroidism, cystinuria
Clinical features bladder stones? (5)
- Suprapubic pain, dysuria
- haematuria usually terminal
- intermittency due to occasional stone impaction at bladder neck- classic symptom!
- bladder outflow obstruction symptoms
- irritative symptoms due to secondary infection
Diagnosis bladder calculus? (3)
- Ultrasound
- AXR: 50% non-opaque (don’t show up)
- cystoscope incidental finding in patient with bladder outflow obstruction
Treatment bladder stones? (2)
- Endoscopic stone fragmentation: cystolitholapaxy
* open cystolithotomy if multiple stones, or open prostatectomy needed to treat bladder outflow obstruction
Clinical features urethral stricture? (3)
- Urinary difficulty: “Thin” stream, “spraying” of stream → suggest distal stricture, absence nocturia
- submeatal or meatal stenosis
- gonococcal strictures → periurethral fibrosis → thickening bulbar urethra palpable in perineum
- palpable unethral mass and bleeding suggest carcinoma
- complications of strictures, local and of outflow obstruction
Investigations for urethral stricture? (5)
. Culture urine, UTI must be treated before urethrogram and treatment.
• flow rates <10 ml/s on uroflowmetry
• urethrogram!
- ascending (retrograde ): inject dye with urethral catheter 2-3 cm into urethra while X-ray screening to give information about anterior urethra
- descending voiding prograde/antegrade: bladder filled with contrast through suprapubic catheter pt then void under xray screening to give info about posterior urethra
- traumatic membranous injury needs simultaneous ascending and descending urethrogram to assess length of “gap’’’
(Cystoscopy)
Treatment urethral stricture? (7 )
• Supra pubic cystostomy if present with any complications!
Minimally invasive
. Dilatation of urethra: retrograde instillation with topical local anaesthetic. Use filiforms and followers (preferred) or metal sounds eg lister’s dilators (complication= “false passage”). Risk bleeding, bactaeraemia/septicaemia, 50% recurrence.
• optical / visual internal urethrotomy (sachse procedure): for short < 2cm strictures in bulbar urethra. Use cystoscope with cold knife at tip and guidewire. Need Indwelling transurethral silastic catheter 1-3 days after. Risk bleeding, false passage, extravasation irrigating fluid into subcutaneous tissue causing infection , septicaemia; 50% recurrence
• intermittent self-dilatation with semi-stiff catheter to reduce recurrence
• urethral stent: expensive, contraindicated post-traumatic strictures
Urethroplasty: only potentially curative method
• excision and end-to-end urethroplasty: for any stricture < 2 cm, all post traumatic strictures
• substitution urethroplasty: part of wall substituted with free tissue graft eg buccal mucosa, or vascularised penile skin flap from shaft, or whole tube replaced with foreskin pedicle flap . indicated for longer strictures, usually inflammatory
Classification of bladder rupture? (3)
Extraperitoneal
• always associated with pelvic #, usually direct penetration of bladder wall by bony fragment
• anterior or lateral bladder wall
Intraperitoneal
• When patient with full bladder sustains blow to lower abdomen
• “burst” type injury so large horizontal tear in dome of bladder
Spontaneous
• no history trauma
• due to underlying urological pathology: urethral stricture with chronic urinary retention, Tb cystitis, bladder carcinoma
Clinical features traumatic bladder injury? (6)
- Unable to void!
- no sign of urethral injury, ie no blood at external urethral meatus
- impalpable bladder
- Urethral catheter → macroscopic haematiuria
- abdominal tender, distension, peritonitis
- suprapubic pain
Definite investigation for bladder injury and features?
Ascending cystogram
Intraperitoneal rupture: extravasation of contrast diffusely in peritoneum cavity . In paracolic gutter
Extrapertoneal: most often pelvic #, contrast extravasation around base bladder, flame-shaped density adjacent to wall
Treatment extraperitoneal bladder rupture? (4)
Most conservative because most small
• urethral catheter 10 days
• broad spectrum antibiotics
• repeat ascending cystogram in 10 days to check of healed
Surgery if: pt already having laparotomy for suspected intraperitoneal injury; associated injury to bladder neck , membranous urethra or rectum.
Treatment intra peritoneal bladder rupture?
Always surgical because: (laparotomy)
• possibility bladder neck, ureter or vaginal injury
• 80% have associated intra-abdominal visceral damage, especially rectum.
Injury to Which part of urethra is associated with fractured pelvis?
Membranous
Injury to Which part of urethra is associated with direct perineal trauma?
Bulbar
Name 5 complications urethral injuries
- Stricture!
- ED
- fistula: urethro-rectal, urethrocutaneous
- periurethral complications: urinary extravasation, periurethral abscess (ant urethra trauma), necrotising fasciitis of perineum, pelvis abscess (post urethra)
- incontinence: post urethra injury, in children, uncommon
Clinical presentation urethral trauma? (5)
- Blood at urethral meatus - urethral bleeding
- high riding prostate (boggy mass felt - pelvic haematoma) = serious injury with wide displacement
- swelling and butterfly perineal haematoma with ant urethra injury
- urinary retention,
- penile and or scrotal haematoma, distended bladder
Investigation of choice for suspected urethral injury?
Ascending retrograde urethrogram!
Treatment blunt urethral trauma?
• Initial suprapubic cystostomy
. Descending urethrogram done 14 days later
• if show complete obstruction, do end - to end unethroplasty 3-6 mouths post injury
Treatment penetrating urethral trauma?
Immediate surgical exploration
Classification and symptoms of LUTS? (11)
Storage / irritative (fun) • frequency • Urgency • urge incontinence OAB • nocturia
Voiding /obstructive (wisd) • Weak stream (stranguria) • intermittency • straining or hesitancy; spraying/splitting • Dysuria (discomfort) • dribbling terminal (due to stranguria)
Post-voiding
• incomplete emptying
• post-micturition dribble
What should be excluded if enuresis? (2)
Vesico-ureteric reflux with indirect cystogram and ultrasound
Neuropathic bladder with ultrasound, mcug, uds
