urinary Flashcards
what are the 2 different types of UTI
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
what is recurrent UTI
≥2 episodes of UTI in 6 months OR ≥ 3 episodes in one year
aetiology of UTI in a young/pre-menopausal person
sexual intercourse
PMH of UTI in childhood
mother with hx of UTI
vesico-ureteric reflex = reversal of urine back into the kidney
aetiology of UTI in a post-menopausal/elderly women
hx of UTI before menopause urinary incontience atrophic vaginitis cystocele inc post void urine volume catheterisation
what is the most common pathogen which causes UTI
E.coli - 90%
other - proteus, klebsiella, saprophytic staphlococci
pseudomonas related to UTI in hospital patients
what are some causes for complicated UTI
structural or neurological abnor of the urinary tract
urinary catheters
virulent or atypical infections organisms
co-morbidities such as DM/immunosuppression
clinical features of lower UTI
dysuria frequency supra-pubic pain urgency incontinence confusion - esp in elderly N+V - paeds
clinical features of upper UTI
fever loin, suprapubic or back pain vomiting loss of appetite haematuria renal angle tenderness
investigation for UTI
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
differential for UTI
STI vaginitis bladder cancer overactive bladder orthostatic proteinuria
what is orthostatic proteinuria
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
management of UTI?
- 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
management of UTI in pregnancy
7 days Abx - even with asymptomatic bacteruria
urine for culture and sensitivity
1st line - nitrofurantoin (avoid in 3rd trimester)
2nd line - cefalexin or amxocillin
aetiology of acute cystitis
infection - E.coli most common
young women
sexuallay active
urinary catheter
DM
spinal cord injuries
pregnancy
lack of circumcision
clinical features of acute cystitis
- Dysuria
- Urgency
- Frequency
- Suprapubic pain and tenderness
investigation for acute cystitis
- Urine dip – +ve for leukocytes, nitrites and blood
- Urine MCS
- PT
management of acute cystitis
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
clinical features of acute pyelonephritis
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
when will you refer a patient with acute pyelonephritis to a hospital?
features of sepsis - hospital referral + BUFALO
community - 7-10 dyas of abx eg
ciprofloxacin
cefalexin
co-amoxiclav
trimethoprime
aetiology of prostatic acute urinary obstruction
BPH
prostatis - which can be caused by UTI, STI
prostate cancer
clinical features of prostatic acute urinary obstruction
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
investigation of prostate acute urinary obstruction
bloods - FBC, U&Es, PSA
urine dip
STI screen
bladder scan
USS KUB
a differential of prostate acute urinary obstruction
overactive bladder UTI
STI
bladder cancer
urethral stricture
what is urethral stricture?
narrowing of the urethra
Men, trauma, STI, prostate surgery, catheterization
blood in the urine/semen, infrequent urination, slow stream, dysuria, suprapubic pain
management of urethral stricture
if BPH
- reassurance and monitoring
- alpha-blocker - tamsulosin 400mcg once daily
- finasteride
surgery - TURP / TUVP
treat prostate cancer
aetiology of severe hyperkalaemia
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
clinical features of hyperkalaemia
asymptomatic
arrhythmia (palpitations, light-headed)
investigation findings od hyperkalaemia?
A-E assessment
ECG
- arrythmia
- flattened P waves
- wide QRS
- sloping ST
- tall tented T waves
- prolong QT syndrome
management of severe hyperkalaemia
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
what is stage 1 AKI
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
what is stage 2 AKI
inc in serum creatinine 2-2.9 x baseline value or
urine output < 0.5 for 12 hours
what is stage 3 AKI
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
aetiolgoy of AKI
> 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
clinical features of AKI
hypovolaemia
- cap refill >2
- tachycardia
- hypotension
- poor skin turgor
- dec urine output
palpable bladder
vasculitis
- weight loss
- fever
- rahs
- uveitis
- haemoptysis
- joint swelling
investigation for AKI
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
management if AKI
STOP AKI
sepsis
toxin - stop/avoid
nephrotoxins
optimise BP - volume status assessment +IV fluids, consider holding antiHTN meds, consider vasopressors
Prevent harm
what are the causes of urge incontinence
overactivity of the detrusor muscle
what are the causes of stress incontinence
weakness of the sphincter
aetiology of urinary incontinence
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
clinical features of urinary incontience
• 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
investigation for stress/urge incontience
- Urination diary
- Urine dipstick +/- MCS
- Bladder USS scan
- Urodynamic testing
management of stress incontinence
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
management of urge incontinence
life style changes
1st line - bladder trainning
2nd line - Oxybutinin or desmopressin
surgical - intra-vesical botox
sacral nerve stimulation
neuromodulator implant
what is a nephrotic symptom?
tetrad –> proteinuria, hypoalbuminaeamia, hypercholesterol, peripheral oedema
due to damage to the podocytes
when is the peak onset of nephrotic syndrome?
between 2 and 5 years old
aetiology of primary nephrotic syndrome
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
aetiology of secondary nephrotic syndrome
diabetic nephropathy
infections eg HIV, hepatitis, malaria
SLE
clinical features of nephrotic syndrome
xanthelasma, xanthomata
SOB, pulmonary oedema, pleural effusion, ankle oedema,
periorbital oedema, ascites
tiredness, leukonychia
frothy urine
inc BP
investigation for nephrotic syndrome
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)
management of nephrotic syndrome
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
complications of nephrotic syndrome
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
what is detrusor instability
spontaneous and uninhibited contraction of the detrusor muscle during bladder filling
aetiology of detrusor instability
idiopathic age stroke dementia MS Parkinsons spinal cord injury Diabetic neuropathy BPH prostate cancer
clinical features of detrusor instability
- 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
investigation for detrusor instability
urine dipstick and MCS
cystometry
Renal US residual urine and bladder wall thickness > 6mm on transvaginal USS
maangement of detrusor instability
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
what is the most commmon type of bladder cancer
90% - transitional cell carcinoma
10% - squamous cell carcinoma
aetiology of bladder cancer
smoking
chemical dyes eg hair dyes, paint, rubber, leather etc
schistosomiasis (flat worm)
male
aged > 55
pelvic radiation
clinical features of bladder cancer
painless haematuria
dysuria
weight loss
investigation of bladder cancer
urinalyisis
cystoscopy + biopsy
management of bladder cancer
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
what is the most common type of prostatic cancer?
95% adenocarcinoma in glandular tissue (posterior/peripheral zone)
how do you distinguish between BPH and prostatic cancer?
BPH normally arise centrally but prostatic cancer arise from peripheral adenoma
what staging score is used for prostate cancer
TNM + Gleeson grading
aetiology of prostatic cancer?
male
inc age
black
tall
use of anabolic steriods
FHX of prostate cancer or breast cancer in mother
BRAC2
clinical features of prostate cancer?
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
investigation for prostatic cancer
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
management of prostatic cancer
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
aetiology of hydronephrosis?
ureteric and pelvicalyceal dilatation
can be uni or bilateral
aetiology of unilateral hydroenphrosis
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
aetiology of bilateral hydronephrosis
congenital posterior urethral valve
congenital/acquired urethral stricture
BPH
large bladder tumors
gravid uterus
clinical features of hydronephrosis
loin pain fever/rigors (if complicated by infection) weak stream AKI renal failure if long-standing
investigations of hydronephrosis
bloods - FBC, U&Es, CRP, culture
MSU - haematuria
renal USS
CT KUB if stone suspected
IV urography
management of calculi induced hydronephrosis
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
management of unilateral hydronephrosis
stent +/- analgesia +/- abx
or
nephrostomy +/- analgesia +/- abx
management of bilateral hydronephrosis
catheter +/- abx
what is the most common type of renal carcinoma?
clear cell 75-90%
papillary 10%
aetiology of renal cell carcinoma
smoking middle age obesity hypertension long term dialysis von Hipple-Lindae disease
aetiology of renal cell carcinoma
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
investigation of renal cell carcinoma
FBC, ferritin, U&Es, LFT, Ca
Contrast CT chest - cannonball Mets
isotope bone scan
management of renal cell carcinoma
surgical - partial or radical nephrectomy
chemo and palliative radio
what are some complications for renal cell carcinoma
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
