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
management of urethral stricture
if BPH - reassurance and monitoring - alpha-blocker - tamsulosin 400mcg once daily - finasteride surgery - TURP / TUVP treat prostate cancer
26
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
27
clinical features of hyperkalaemia
asymptomatic | arrhythmia (palpitations, light-headed)
28
investigation findings od hyperkalaemia?
A-E assessment ECG - arrythmia - flattened P waves - wide QRS - sloping ST - tall tented T waves - prolong QT syndrome
29
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
30
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
31
what is stage 2 AKI
inc in serum creatinine 2-2.9 x baseline value or urine output < 0.5 for 12 hours
32
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
33
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
34
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
35
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
36
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
37
what are the causes of urge incontinence
overactivity of the detrusor muscle
38
what are the causes of stress incontinence
weakness of the sphincter
39
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
40
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
41
investigation for stress/urge incontience
* Urination diary * Urine dipstick +/- MCS * Bladder USS scan * Urodynamic testing
42
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
43
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
44
what is a nephrotic symptom?
tetrad --> proteinuria, hypoalbuminaeamia, hypercholesterol, peripheral oedema due to damage to the podocytes
45
when is the peak onset of nephrotic syndrome?
between 2 and 5 years old
46
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
47
aetiology of secondary nephrotic syndrome
diabetic nephropathy infections eg HIV, hepatitis, malaria SLE
48
clinical features of nephrotic syndrome
xanthelasma, xanthomata SOB, pulmonary oedema, pleural effusion, ankle oedema, periorbital oedema, ascites tiredness, leukonychia frothy urine inc BP
49
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)
50
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
51
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
52
what is detrusor instability
spontaneous and uninhibited contraction of the detrusor muscle during bladder filling
53
aetiology of detrusor instability
``` idiopathic age stroke dementia MS Parkinsons spinal cord injury Diabetic neuropathy BPH prostate cancer ```
54
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
55
investigation for detrusor instability
urine dipstick and MCS cystometry Renal US  residual urine and bladder wall thickness > 6mm on transvaginal USS
56
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
57
what is the most commmon type of bladder cancer
90% - transitional cell carcinoma | 10% - squamous cell carcinoma
58
aetiology of bladder cancer
smoking chemical dyes eg hair dyes, paint, rubber, leather etc schistosomiasis (flat worm) male aged > 55 pelvic radiation
59
clinical features of bladder cancer
painless haematuria dysuria weight loss
60
investigation of bladder cancer
urinalyisis | cystoscopy + biopsy
61
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
62
what is the most common type of prostatic cancer?
95% adenocarcinoma in glandular tissue (posterior/peripheral zone)
63
how do you distinguish between BPH and prostatic cancer?
BPH normally arise centrally but prostatic cancer arise from peripheral adenoma
64
what staging score is used for prostate cancer
TNM + Gleeson grading
65
aetiology of prostatic cancer?
male inc age black tall use of anabolic steriods FHX of prostate cancer or breast cancer in mother BRAC2
66
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
67
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
68
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
69
aetiology of hydronephrosis?
ureteric and pelvicalyceal dilatation can be uni or bilateral
70
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
71
aetiology of bilateral hydronephrosis
congenital posterior urethral valve congenital/acquired urethral stricture BPH large bladder tumors gravid uterus
72
clinical features of hydronephrosis
``` loin pain fever/rigors (if complicated by infection) weak stream AKI renal failure if long-standing ```
73
investigations of hydronephrosis
bloods - FBC, U&Es, CRP, culture MSU - haematuria renal USS CT KUB if stone suspected IV urography
74
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
75
management of unilateral hydronephrosis
stent +/- analgesia +/- abx or nephrostomy +/- analgesia +/- abx
76
management of bilateral hydronephrosis
catheter +/- abx
77
what is the most common type of renal carcinoma?
clear cell 75-90% | papillary 10%
78
aetiology of renal cell carcinoma
``` smoking middle age obesity hypertension long term dialysis von Hipple-Lindae disease ```
79
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
80
investigation of renal cell carcinoma
FBC, ferritin, U&Es, LFT, Ca Contrast CT chest - cannonball Mets isotope bone scan
81
management of renal cell carcinoma
surgical - partial or radical nephrectomy chemo and palliative radio
82
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