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Year 5 Conditions > urinary > Flashcards

urinary Flashcards

1
Q

what are the 2 different types of UTI

A

uncomplicated - typical pathogens, normal urinary tract and kidney function, no predisposing co-morbidities

complicated - UTI with an increased likelihood of complications such as persistent infection, treatment failure and recurrent infection

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2
Q

what is recurrent UTI

A

≥2 episodes of UTI in 6 months OR ≥ 3 episodes in one year

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3
Q

aetiology of UTI in a young/pre-menopausal person

A

sexual intercourse
PMH of UTI in childhood
mother with hx of UTI

vesico-ureteric reflex = reversal of urine back into the kidney

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4
Q

aetiology of UTI in a post-menopausal/elderly women

A 
hx of UTI before menopause 
urinary incontience 
atrophic vaginitis 
cystocele 
inc post void urine volume 
catheterisation
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5
Q

what is the most common pathogen which causes UTI

A

E.coli - 90%
other - proteus, klebsiella, saprophytic staphlococci

pseudomonas related to UTI in hospital patients

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6
Q

what are some causes for complicated UTI

A

structural or neurological abnor of the urinary tract

urinary catheters

virulent or atypical infections organisms

co-morbidities such as DM/immunosuppression

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7
Q

clinical features of lower UTI

A 
dysuria
frequency 
supra-pubic pain 
urgency 
incontinence 
confusion - esp in elderly 
N+V - paeds
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8
Q

clinical features of upper UTI

A 
fever 
loin, suprapubic or back pain 
vomiting 
loss of appetite 
haematuria 
renal angle tenderness
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9
Q

investigation for UTI

A

urine dip - nitrites and leukocytes + nitrites alone

MSU if nitrite and leukocytes present

if elderly - MSC straight away

PR for men - BPH?

USS and referral?

CTKUB - if suspected pyelonephritis, frank haematuria, men, paeds

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10
Q

differential for UTI

A 
STI 
vaginitis 
bladder cancer 
overactive bladder 
orthostatic proteinuria
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11
Q

what is orthostatic proteinuria

A

inc protein excretion during the day associated with activity and upright posture

normal

common in young adults, male

+ve urine dip for proteins during the day, -ve with early morning sample

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12
Q

management of UTI?

A
  • 3 days of trimethoprim/nitrofurantoin for a simple lower urinary tract infection in women
  • 5-10 days of antibiotics for women that are immunosuppressed, have abnormal anatomy or impaired kidney function
  • 7 days of trimethoprim/nitrofurantoin for men, pregnancy women or catheter related UTIs

analgeis
change catheter if cather related

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13
Q

management of UTI in pregnancy

A

7 days Abx - even with asymptomatic bacteruria

urine for culture and sensitivity

1st line - nitrofurantoin (avoid in 3rd trimester)

2nd line - cefalexin or amxocillin

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14
Q

aetiology of acute cystitis

A

infection - E.coli most common

young women

sexuallay active

urinary catheter

DM

spinal cord injuries

pregnancy

lack of circumcision

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15
Q

clinical features of acute cystitis

A
  • Dysuria
  • Urgency
  • Frequency
  • Suprapubic pain and tenderness
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16
Q

investigation for acute cystitis

A
  • Urine dip – +ve for leukocytes, nitrites and blood
  • Urine MCS
  • PT
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17
Q

management of acute cystitis

A

Abx – community choices inc. trimethoprim or nitrofurantoin
• 3 days of antibiotics for a simple lower urinary tract infection in women
• 5-10 days of antibiotics for women that are immunosuppressed, have abnormal anatomy or impaired kidney function
• 7 days of antibiotics for men, pregnancy women or catheter related UTIs
2) Change catheter

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18
Q

clinical features of acute pyelonephritis

A 
Fever high temps +/- chills 
loin, suprapubic or back pain - can be bilateral or unilateral 
dysuria 
frequency 
urgency 
N+V 
loss of appetite
renal angle tenderness on examination
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19
Q

when will you refer a patient with acute pyelonephritis to a hospital?

A

features of sepsis - hospital referral + BUFALO

community - 7-10 dyas of abx eg

ciprofloxacin
cefalexin
co-amoxiclav
trimethoprime

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20
Q

aetiology of prostatic acute urinary obstruction

A

BPH
prostatis - which can be caused by UTI, STI
prostate cancer

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21
Q

clinical features of prostatic acute urinary obstruction

A 
urgency 
difficulty initiating urination 
strainning to void 
dec force of stream 
incomplete emptying 
terminal dribbing 
distended/aplpable bladder 
haematuria 
fever/pain/tenderness of the prostate and in he suprapubic region or lower back = prostatis PR exma - large/irregualr prostate
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22
Q

investigation of prostate acute urinary obstruction

A

bloods - FBC, U&Es, PSA

urine dip

STI screen

bladder scan

USS KUB

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23
Q

a differential of prostate acute urinary obstruction

A

overactive bladder UTI
STI
bladder cancer
urethral stricture

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24
Q

what is urethral stricture?

A

narrowing of the urethra

Men, trauma, STI, prostate surgery, catheterization

blood in the urine/semen, infrequent urination, slow stream, dysuria, suprapubic pain

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25
Q

management of urethral stricture

A

if BPH

  • reassurance and monitoring
  • alpha-blocker - tamsulosin 400mcg once daily
  • finasteride

surgery - TURP / TUVP

treat prostate cancer

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26
Q

aetiology of severe hyperkalaemia

A

oliguria acute kidney injury

K+ sparing duretics - amiloride, spirolactone

drugs - ACEs, ARB

iatrogenic - exces K+ infusion

massive blood transfusion

artefact - haemolysis

metabolic acidosis

rhabdomyolysis

Addison’s Disease

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27
Q

clinical features of hyperkalaemia

A

asymptomatic

arrhythmia (palpitations, light-headed)

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28
Q

investigation findings od hyperkalaemia?

A

A-E assessment

ECG

  • arrythmia
  • flattened P waves
  • wide QRS
  • sloping ST
  • tall tented T waves
  • prolong QT syndrome
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29
Q

management of severe hyperkalaemia

A

A-E assessment

immediate treatment if K > 6 wit hECG changes or > 6.5 with or without ECG changes

1) calcium gluconate IV 30ml 10% bolus over 2 mins (or calcium chlorid 10mls over 5-10 mins) - repeat after 5-10 mins if no improvement
2) insulin 10 units actrapid over 5-10 mins and 50% dextrose 50ml IV over 5-10 mins
3) salbutamol 5mg neb back to back over 10-20 mins
4) calcium resonium 15g orally every 6-8 hours
5) haemofiltration/dialysis if not responding to above

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30
Q

what is stage 1 AKI

A

inc in serum creatinine > 26 within 48 hours or

inc in creatinine 1.5-1.9 x baseline value or

urine output < 0.5 ml/kg/hr for 6 hours

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31
Q

what is stage 2 AKI

A

inc in serum creatinine 2-2.9 x baseline value or

urine output < 0.5 for 12 hours

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32
Q

what is stage 3 AKI

A

inc in serum creatinine > 33x baseline or

> 354 inc in creatinine or

commenced on renal replacement therapy or

urine output < 0.3 for 24 hours or

anuric for 12 hours

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33
Q

aetiolgoy of AKI

A 
> 75 
CKD 
HTN 
HTN meds 
cardiac failure 
liver disease 
DM 
nephrotoxins 
hypovolaemia 
sepsis

pre-renal - hypovolaemia, hypotension, sepsis, cardiac failrue

intrinsic - prolong hypoperfusion, nephrotoxins, glemerulonephritis, vasculitis

post-renal - obsturction

34
Q

clinical features of AKI

A

hypovolaemia

  • cap refill >2
  • tachycardia
  • hypotension
  • poor skin turgor
  • dec urine output

palpable bladder

vasculitis

  • weight loss
  • fever
  • rahs
  • uveitis
  • haemoptysis
  • joint swelling
35
Q

investigation for AKI

A

FBC, U&Es, Calcium, Phosphate, Bicarbonate, LFTs, consider blood cultures if sepsis suspected

Urine dipstick (presence of blood and protein suggests infection or vasculitis)

CXR -pulmonary filtrates = fluid, infection or haemorrhage

renal tract USS

36
Q

management if AKI

A

STOP AKI

sepsis

toxin - stop/avoid
nephrotoxins

optimise BP - volume status assessment +IV fluids, consider holding antiHTN meds, consider vasopressors

Prevent harm

37
Q

what are the causes of urge incontinence

A

overactivity of the detrusor muscle

38
Q

what are the causes of stress incontinence

A

weakness of the sphincter

39
Q

aetiology of urinary incontinence

A

altered anatomical support of pelvic floor eg vaginal delivery, pelvic organ prolapses

altered neuromusclar function of the pelvic floor eg Parkinson’s, MS

dementia

UTI

constipation

faecal incontinence

high impact physical activity

caffeine

idiopathic

40
Q

clinical features of urinary incontience

A

• Involuntary urine leakage – on effort/exertion/sneezing/coughing (stress) OR accompanied by or immediately preceded by urgency (urge)

frequency of urination

vaginal bulge/pressure

urogenital atrophy

nocturia

urine leakage during empty stress test - patient performs valsalva manoeuvre whilst in the doral lithoyom posisition after voiding, if leakage = +ve test

41
Q

investigation for stress/urge incontience

A
  • Urination diary
  • Urine dipstick +/- MCS
  • Bladder USS scan
  • Urodynamic testing
42
Q

management of stress incontinence

A

weight loss, smoking cessation, treatment of chronic cough and constipation, avoid caffeine etc

1) pelvic floor exercise for 3 months
2) Duloxetine (SNRI)
3) surgical
- tension free vaginal tape procedure
- transobturator tape

43
Q

management of urge incontinence

A

life style changes

1st line - bladder trainning
2nd line - Oxybutinin or desmopressin

surgical - intra-vesical botox
sacral nerve stimulation
neuromodulator implant

44
Q

what is a nephrotic symptom?

A

tetrad –> proteinuria, hypoalbuminaeamia, hypercholesterol, peripheral oedema

due to damage to the podocytes

45
Q

when is the peak onset of nephrotic syndrome?

A

between 2 and 5 years old

46
Q

aetiology of primary nephrotic syndrome

A

minimal change disease - loos of podocyte foot projection (90%) in childhod

focal segmental glomerulosclerosis - glomerueobasement memebren thickening

membranous glomerulonephritis - glumeruobasement membrane thickening via immunocomplex deposition which damage podocytes

47
Q

aetiology of secondary nephrotic syndrome

A

diabetic nephropathy

infections eg HIV, hepatitis, malaria

SLE

48
Q

clinical features of nephrotic syndrome

A

xanthelasma, xanthomata
SOB, pulmonary oedema, pleural effusion, ankle oedema,

periorbital oedema, ascites

tiredness, leukonychia

frothy urine

inc BP

49
Q

investigation for nephrotic syndrome

A

urine dip + urine MC+S
- +ve for proteins

FBC, CRP, U&Es, LFT, clotting, HbA1c

  • dec albumin
  • inc serum chloesterol, triglycerides
  • inc clotting

complement levels - C3, C4

Antistreptolysin O or anti-DNAse B titres and throat swab

HepB/C, HIV

CXR - pulmonary oedema +/- pleural effusion

USS + renal biopsy - electron microscopy shows diffuse effacement of the epitheial cell foot processes (shortening of gaps between the cells of glomerulus that allow for filtration)

50
Q

management of nephrotic syndrome

A

A specialist pediatrician with input from renal specialists

  • fluid and salt restriction
  • high dose prednisolone - given for 4 weeks then gradually weekend over the next 8 weeks
  • +/- diuretics
  • severe = albumin infusion and abx
  • steroid resistance - ACEi and immunosuppressant eg cyclosporine
51
Q

complications of nephrotic syndrome

A

hypovolaemia - urgent IV albumin

thrombosis - a hypcoagulable state due to haemoconcentration and loss of antithrombin

infection - kidney also leaks immunoglobulins, so risk of infection

acute/chronic renal failure

52
Q

what is detrusor instability

A

spontaneous and uninhibited contraction of the detrusor muscle during bladder filling

53
Q

aetiology of detrusor instability

A 
idiopathic 
age 
stroke 
dementia 
MS 
Parkinsons 
spinal cord injury 
Diabetic neuropathy 
BPH
prostate cancer
54
Q

clinical features of detrusor instability

A
  • Urinary frequency
  • Urgency
  • Urge incontinence
  • Nocturia
  • Nocturnal enuresis (bed wetting)
  • Provocative factors often trigger it (e.g. cold weather, opening the front door, hearing running water).
  • Bladder contractions may be provoked by  in intra-abdominal pressure (coughing or sneezing) leading to complaint of stress incontinence which may be misleading
55
Q

investigation for detrusor instability

A

urine dipstick and MCS
cystometry

Renal US  residual urine and bladder wall thickness > 6mm on transvaginal USS

56
Q

maangement of detrusor instability

A

conservative mx - weight loss, avoid caffeine based drinks, smoking cessation, drink less water

bladder drills

pelvic floor muscle trainnning

biofeedback - device to convert effect of pelvic floor contractyion into a visal signal

electrical stimulation - can assist in thoe who can not produce a muscle contraction

meds - oxybutynin, intravaginal oestrogen maybe tried for vaginal atrophy

surgical - last resort - bladder distension, sacral neuromodulation, detrusor myomectomy and augmentation cystoplasty

botox

57
Q

what is the most commmon type of bladder cancer

A

90% - transitional cell carcinoma

10% - squamous cell carcinoma

58
Q

aetiology of bladder cancer

A

smoking

chemical dyes eg hair dyes, paint, rubber, leather etc

schistosomiasis (flat worm)

male

aged > 55

pelvic radiation

59
Q

clinical features of bladder cancer

A

painless haematuria
dysuria
weight loss

60
Q

investigation of bladder cancer

A

urinalyisis

cystoscopy + biopsy

61
Q

management of bladder cancer

A

non-invasive
- TURBT
+chemo adjuvant
+ weekly treatmetn for 6 weeks of BCG vaccines squirted into the bladder –> every 6 months for 3 years

if muscle invasive
- radical cystectomy + radio (neoaadjuvant, primar or palliative treatement) +/- IV chemo neoadjuvant or palliative

62
Q

what is the most common type of prostatic cancer?

A

95% adenocarcinoma in glandular tissue (posterior/peripheral zone)

63
Q

how do you distinguish between BPH and prostatic cancer?

A

BPH normally arise centrally but prostatic cancer arise from peripheral adenoma

64
Q

what staging score is used for prostate cancer

A

TNM + Gleeson grading

65
Q

aetiology of prostatic cancer?

A

male
inc age
black
tall

use of anabolic steriods

FHX of prostate cancer or breast cancer in mother

BRAC2

66
Q

clinical features of prostate cancer?

A 
haematuria 
nocturia 
urinary frequency 
urinary hesiancy 
dysuria

erectile dysfunction/blood in semen

fever, night sweats, weight loss

mets - bone pain, anaemia, pathological fractures, MSCC

PR exam - firm/hard, asymmetrical, craggy or irregular with loss of central sulcus

67
Q

investigation for prostatic cancer

A

FBC, U&E,s LFT, PSA (> 3 is raised), testosterone
- PSA also raised in UTI, ejaculation 48 hours ago, trauma/recent instumentation

prostate biopsy via
- TRUS or transperineal

MRI

radionuclide bone scan for mets

68
Q

management of prostatic cancer

A

low risk

  • acitve surveillance - via MRI and yearly biopsies
  • wat and wait - yearly PSA, indicated for older men wit hco-morbidities

moderate/high risk

  • surgery
  • radiotherapy
  • brachytherapy
  • antiandrogen thrapy - bilateral orchiectomy, LHRH agonist eg goserelin, androgen receptor blockers eg Bicalutamide, oestrogen therapy
69
Q

aetiology of hydronephrosis?

A

ureteric and pelvicalyceal dilatation

can be uni or bilateral

70
Q

aetiology of unilateral hydroenphrosis

A

extramural - extrinsic tumour eg cervix, prostate, large bowel, AAA, idiopathic retroperitneal fibrosis, post radiation fibrosis

intrmural - transitional cell carcinoma of the renal pelvis/ureter, ureteric strictures

intra-luminal
- urinary calculi

71
Q

aetiology of bilateral hydronephrosis

A

congenital posterior urethral valve

congenital/acquired urethral stricture

BPH

large bladder tumors

gravid uterus

72
Q

clinical features of hydronephrosis

A 
loin pain 
fever/rigors (if complicated by infection)
weak stream 
AKI
renal failure if long-standing
73
Q

investigations of hydronephrosis

A

bloods - FBC, U&Es, CRP, culture

MSU - haematuria

renal USS

CT KUB if stone suspected

IV urography

74
Q

management of calculi induced hydronephrosis

A

if stone + septic

  • anagleia, fluid,
  • nephrostomy/utreteric stent
  • ABX

if stone + non-spetic
- anaglesia, fluids
alpha blocker (tamsulosin)/active stone removal or nephrostomy/ureteric stent if large

75
Q

management of unilateral hydronephrosis

A

stent +/- analgesia +/- abx

or

nephrostomy +/- analgesia +/- abx

76
Q

management of bilateral hydronephrosis

A

catheter +/- abx

77
Q

what is the most common type of renal carcinoma?

A

clear cell 75-90%

papillary 10%

78
Q

aetiology of renal cell carcinoma

A 
smoking 
middle age 
obesity 
hypertension 
long term dialysis 
von Hipple-Lindae disease
79
Q

aetiology of renal cell carcinoma

A

mostly asymptomatic
painless haematuria
loin pain
feeling of a mass arising from the flank
varicocelle - due to compression of the renal vein between the abdominal aorta and superior mesenteric vein
weight loss, faigue, night sweats

80
Q

investigation of renal cell carcinoma

A

FBC, ferritin, U&Es, LFT, Ca

Contrast CT chest - cannonball Mets

isotope bone scan

81
Q

management of renal cell carcinoma

A

surgical - partial or radical nephrectomy

chemo and palliative radio

82
Q

what are some complications for renal cell carcinoma

A

SSHARP

Stauffer syndrome - abnor LFT demonstrating a jundice picture - without any localised liver or billary mets

SIADH

Hypercalcaemia - RCC secretes a hormone that micmics the action of PTH

anaemia

Renal vein thrombosis

polycythaemia - erythropoietin

Year 5 Conditions (19 decks)

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