Urinary diseases Flashcards
How does a UTI present?
Dysuria (pain on micturition), frequency and smelly urine.
- If very young = unwell, failure to thrive
- Very old = incontinence, off their feet
What is a UTI?
Urinary tract infection
What are the bacteriostatic properties of a normal urinary tract?
- Free flow of urine through normal anatomy - assume drinking enough fluids.
- Low pH, high osmolarity, and high ammonia content of normal urine
- Prostatic secretions are bacteriostatic
- anti-bacterial antibodies
Is a normal renal tract sterile?
Urinary tract sterile except for terminal urethra which contains perineal and gut flora.
Why do we want a Mid Stream Specimen of urine?
Urethra flora diminished but always present.
Patients void and stop mid stream, discarding urine then collects next volume.
How can we tell contamination is from real infection?
MSSU - microbiology for culture under set conditions.
Can count the number of bacteria - 10 to power 5 = usually infection. (99% accuracy)
10 to power 3-4 = infections sometimes ( if symptoms) more likely.
Less than 10 to 3 = usually no infection.
What are the main micro-organisms that cause UTI?
Gut flora - especially E.coli
Viral infection rare.
What is the route of infection?
Almost always ascending: Infection in kidneys usually infection has spread up from bladder. Upper UTI = more serious.
What is:
- Urethritis
- Cystitis
- Ureteritis
- Acute/chronic pyelonephritis?
- Inflammation of urethra
- Inflammation of bladder
- Inflammation of ureter
- Inflammation of kidney / If recurrent to prolonged chronic inflammation.
What are the predisposing factors to UTI?
- Stasis of urine
- Pushing bacteria up urethra from below
- Generalised predisposition to infection
What can cause stasis of urine?
- Obstruction, congenital or acquired
2. Loss of feeling of full bladder - spinal cord/brain injury
What can cause pushing bacteria up urethra from below?
- sexual activity in females
2. Catheterisation (other urological procedures)
What are the consequences of obstruction?
- Proximal dilatation
- slowed urine flow - cannot flush out bacteria - infection
- Slowed urine flow - sediments form calculous (stone) formation - obstruction
- Triad - infection - calculi - obstruction.
What are the common causes of obstruction in adults?
Men - benign prostatic hyperplasia of prostate - functional and anatomical obstruction.
Women - uterine prolapse
Both sexes - tumours and calculi.
What can causes obstruction in children?
Numerous renal tract abnormalities
Most important example = vesicoureteric reflux.
What is vesicoureteric reflux?
Decreased angulation - bladder - ureter reflux.
How does sexual activity in females cause UTI?
Tends to move lower urethral flora up the tract (back wall of urethra is just in front of vagina)
- Short urethra
- Lack of prostatic bacteriostatic secretion
- Closeness of urethral orifice to rectum
- pregnancy - pressure on ureters and bladder.
What are some of the generalised predisposition to infection that cause UTI’s?
Glucose in urine - diabetes
Poor function of WBC
What are the complications of UTI?
- Acute
- Chronic
- Severe sepsis and septic shock (bacteria get into blood)
- Chronic damage to kidneys if repeated infections - lead to hypertension, chronic renal failure
- Calculi - obstruction - hydroneophrosis.
What is contained in the filter barrier of the glomerulus?
Membrane:
Endothelial cell cytoplasm, basal lamina (connective tissue) and podocyte.
What are mesangial cells>
“tree like” group of cells which support capillaries
What is Glomerulonephritis?
Disease of glomerulus
Inflammatory or non-inflammatory
Primary or secondary.
Causes of Glomerulonephritis
Immunoglobulin depostition
Some are diseases with no immunoglobulin deposition e.g. diabetic glomerular disease.
What are the 4 common presentations of Glomerulonephritis?
- Haematuria (blood in urine)
- Heavy proteinuria (nephrotic syndrome)
- Slowly increasing proteinuria
- Acute renal failure
What are the main causes of Haematuria?
UTI
UT stone
UT tumour
Glomerulonephritis
Causes of IgA glomerulonephritis? (GN)
Unknown - could be excess antibody produced?
What happens in IgA GN?
Mesangium becomes clogged with antibody. Red blood cells then escape into urine. Causes proliferation and production of more matrix.
What is prognosis of IgA nephropathy?
Usually self-limiting, i.e. return to normal
Small percent go onto chronic renal failure.
What happens in Membranous glomerulonephritis?
Thickened glomerular basement membrane
IgG stuck in membrane - between basal lamina dn podocyte.
IgG too big to be filtered into urine. But activates complement which punches holes in filter.
What does the leaky filter cause?
Albumin to be filtered into urine - nephrotic syndrome
Prognosis of Membranous GN?
1/4 chronic renal failure within 10 years.
Diabetic nephropathy prognosis
Inevitable decline if established or continued poor diabetic control.
What is Crescentic GN?
Granulomatosis with polyangiitis - form of vasculitis (inflammation in vessels)
Antiglomerular basement membrane disease.
Wegener’s prognosis
Fatal if left untreated.
When thinking of what could be the cause of symptoms and presentation what should we think about?
Surgical sieve
Infection Inflammation Iatrogenic Neoplasia Trauma Degenerative Congenital Genetic/Hereditary Vascular Endocrine Failure Idiopathic
Nature of renal diseases what are we looking for?
Infection - pyelonephritis
Inflammation - glomerulonephritis
Iatrogenic - nephrotoxicity, PCNL
Neoplasia - renal tumours, collecting system tumours
Trauma - blunt
Vascular - atherosclerosis, hypertension, diabetes
Hereditary - polycystic kidney disease, nephrotic syndrome
Presentation of renal diseases
Pain Pyrexia Haematuria Proteinuria Pyuria (leukocytes) Mass on palpation Renal failure
Define proteinuria
Urinary protein excretion > 150mg/day
How many types of haematuria are there?
3 - microscopic, macroscopic and dip stick
What is the definition of microscopic haematuria?
> 3 or equal to 3 red blood cells per high power field.
Define the following:
- Oliguria
- Anuria
- Polyuria
- Nocturia
- Nocturnal polyuria
- Urine output < 0.5 ml/kg/hour
- Absolute anuria = no urine output; relative = <100ml/24hr
- Urine output > 3l/24hr
- Waking up at night are than 1 occasion to pee
- Nocturnal urine output > 1/3 of total urine output in 24 hr (frequency volume chart)
Acute kidney injury:
What is the RIFLE staging criteria?
- Risk - increase in serum creatinine level (1.5x) or decrease in GFR by 25%. UO <0.5ml for 6 hr
- Injury - increase in serum creatinine level (2x) or decrease in GFR by 50%. UO<0.5ml for 12 hr
- Failure - Increase serum creatinine level (3x), decrease in GFR by 75% or UO < 0.3 for 24hr or Anuria for 12 hr
- Loss - persistent ARF or complete loss of kidney function > 4 weeks
- End stage kidney disease - completely loss of kidney function > 3 months
Chronic renal failure:
Presentation
Asymptomatic (found on blood and urine testing) Tiredness Anemia Oedema High Blood pressure Bone pain due to renal bone disease Pruritus (in advanced and all below) Nausea/vomiting Dyspnoea Pericarditis Neuropathy Coma
Presentation of ureteric diseases
Pain (renal colic 10/10) Pyrexia Haematuria Palpable mass Renal failure (only if bilateral obstruction or single functioning kidney)
What are the different natures of ureteric disease?
- Infection - ureterirtis
- Trauma/Iatrogenic - hysterectomy or inadvertently cut.
- Neoplasia - TCC of ureter or bladder obstructing VUJ, prostate cancer. (transitional cell carcinoma)
- Hereditary - PUJ obstruction, VUJ reflux
- Obstruction
- intra-luminal (stone, blood clot)
- intra-mural (scar tissue, TCC)
- Extra-luminal (pelvic mass, lymph nodes)
Natures of bladder disease
- Infection - cystitis
- Inflammation - interstitial cystitis, colonic diverticulitis
- Iatrogenic/trauma - Bladder rupture, bladder injury from hysterectomy
- Neoplasia - TCC of bladder, SCC of bladder
- Idiopathic - overactive bladder syndrome
- Degenerative - Chronic urinary retention
- Neurological - neurogenic bladder dysfunction
Presentation of bladder disease
Pain (suprapubic)
Pyrexia
Haematuria
LUTS:
- storage - frequency, nocturne, urgency, urge
- Voiding - poor flow, intermittency, terminal dribbling - underachieve bladder
- Incontinence - stress, urge, mixed,overflow
Nature of bladder outflow tract diseases
Infection/inflammation - prostates, balanitis
Iatrogenic/trauma - pelvic floor damage, urethral injury
Neoplasia - prostate cancer, penile cancer
Idiopathic - chronic pelvic pain syndrome
OBSTRUCTION - primary bladder neck obstruction, benign prostatic enlargement, urethral stricture, metal stenosis.
Presentation of bladder outflow tract diseases
Pain Pyrexia Haematuria Lower urinary tract symptoms Recurrent UTIs Acute urinary retention Chronic urinary retention
Define acute urinary retention
Painful inability to void with a palpable and percusible bladder.
- BPO
Define Chronic urinary retention
Painless, palpable and permissible bladder after voiding.
- detrusor under activity
What types of organisms can be seen in a UTI?
E.coli Staph saprophyticus Klebsiella proteus Pseudomonas Staph aureus
Complications of UTI
Infective sepsis Renal failure Bladder malignancy Acute urinary retention Bladder/renal stones frank haematuria
Treatment for UTI
Appropriate oral antibiotic therapy
Treat complications and cause.
Investigations for UTI
Urine dipstick
Urine microscopy
Culture and sensitivity
How do we assess for kidney disease?
Filtration (excretory) function - remove
Filtration (barrier) function - retain
Anatomy - structural abnormality
How do we measure excretory Renal function?
Isotope GFR used if someone is donating a kidney.
Used all the time is serum creatinine to measure eGFR.
What is the problem with using creatinine?
generated from breakdown of muscle and not everyone has same muscle mass - depends on age, ethnicity, gender, weight.
Also It will not be raised above normal range until 60% of total kidney function is lost.
