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MSRA Content > Urinary System - Level 1 > Flashcards

Urinary System - Level 1 Flashcards

1
Q

Definition of bacteriuria?

A

o presence of bacteria in the urine. This may be symptomatic or asymptomatic. Asymptomatic bacteriuria should be confirmed by two consecutive urine samples

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2
Q

Definition of UTI?

A

o presence of characteristic symptoms and significant bacteriuria from kidneys to bladder
o >105 (cfu/ml)

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3
Q

Types of UTI?

A

o Lower UTI = infection of the bladder (cystitis)

o Upper UTI = infection of kidney and ureters (acute pyelonephritis)

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4
Q

Classifications of UTI?

A

o Uncomplicated – normal renal tract/function

o Complicated – abnormal renal tract, obstruction, decreased renal function, immunocompromised

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5
Q

Epidemiology of UTIs?

A
  • Incidence is 5% in UK
  • More common in females due to short urethra
  • 40% have genitourinary anomalies
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6
Q

Risk factors of UTIs?

A 
o	Women
o	Sexual intercourse
o	Catheter
o	Abnormality of renal tract
o	Antibiotic use
o	Pregnancy
o	Immunocompromise
o	Diabetes Mellitus
o	Spermide
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7
Q

Causative organisms of UTIs?

A

o E. coli in 90% of cases
o Proteus (present under prepuce)
o Klebsiella
o Enterococcus faecalis
o Saprophytic staphylococci (young women)
o Pseudomonas (may indicate structural damage in urinary tract)

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8
Q

Symptoms of lower UTIs?

A 
o	Dysuria
o	Frequency
o	Urgency
o	Haematuria
o	Suprapubic discomfort
o	Burning
o	Cloudy urine with offensive smell
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9
Q

Investigations in lower UTI?

A
  • Urine dipstick MSU
    o Leukocytes and nitrites, haematuria and proteinuria
  • Urine M, C&S
    o Male, child under 16, pregnant, very ill
    o May show leukocytes, RBC commonly seen, renal pathology if crystals or granular casts found
  • Renal USS (KUB)
    o If recurrent or complicated
  • Bloods
    o FBC, U&Es, CRP, cultures if unwell
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10
Q

Management of lower UTI - referral?

A
  • Referral to hospital if sepsis suspected
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11
Q

Management of lower UTI - general advice?

A

o Paracetamol for pain
o Hygiene: clean perineum front to back
o Increase fluid intake
o Voiding after intercourse

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12
Q

Management of lower UTI - in non-pregnant women?

A

o Back-up antibiotic or immediate prescription, depending on clinical picture
 Back-up prescription should be used if no improvement in 48 hours of taking antibiotic or worsens

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13
Q

Management of lower UTI - non-pregnant women - antibiotics - first & second choice?

A

First Choice
• Nitrofurantoin (if eGFR>45) 100mg MR BD for 3 days
• Trimethoprim 200mg BD for 3 days

Second Choice (worsening UTI on first choice for >48 hours)
•	Nitrofurantoin (if eGFR>45 and not first choice) 100mg MR BD for 3 days
•	Pivmecillinam 400mg initial dose then 200mg TDS for 3 days
•	Fosfomycin 3g single dose sachet
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14
Q

Management of lower UTI - pregnant women, men and children - investigations?

A

 Midstream urine for M, C & S in pregnant women, men and children <16

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15
Q

Management of lower UTI - antibiotics children <16 years old - under 3 months?

A

• Under 3 months – refer to paediatric specialist

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16
Q

Management of lower UTI - antibiotics children <16 years old - over 3 months?

A

o First Choice
 Nitrofurantoin (if eGFR>45) for 3 days
 Trimethoprim for 3 days

o Second choice
 Nitrofurantoin (if eGFR>45) for 3 days
 Amoxicillin for 3 days
 Cefalexin for 3 days

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17
Q

Management of lower UTI - antibiotics men first choice?

A 
o	Nitrofurantoin (if eGFR>45) 100mg MR BD for 7 days
o	Trimethoprim 200mg BD for 7 days

Follow up in 48 hours

If not working consider alternative diagnosis

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18
Q

Management of lower UTI - antibiotics - pregnant women - first & second choice?

A 
•	First choice
o	Nitrofurantoin (if eGFR >45) 100mg MR BDS for 7 days

Second choice
o Amoxicillin (only if cultures results available) 500mg TDS for 7 days
o Cefalexin 500mg BDS for 7 days

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19
Q

Management of lower UTI - antibiotics - in asymptomatic bacteriuria?

A

• Nitrofurantoin, amoxicillin or cefalexin

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20
Q

Management of lower UTI - catheterised patients - general management?

A

o Remove catheter or changing as soon as possible if been in place for >7 days
o Obtain urine sample via sampling port

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21
Q

Management of lower UTI - catheterised patients - non-pregnant women and men >16 - antibiotics if lower symptoms?

A

o First choice
 Nitrofurantoin, trimethoprim, amoxicillin (only if cultures available)

o Second choice
 Pivmecillinam

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22
Q

Management of lower UTI - catheterised patients - non-pregnant women and men >16 - antibiotics if upper symptoms?

A

o First choice
 Cefalexin, ciprofloxacin, co-amoxiclav, trimethoprim

o First choice IV
 Co-amoxiclav, cefuroxime, ceftriaxone, gentamicin, amikacin

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23
Q

Management of lower UTI - catheterised patients - pregnant women - antibiotics?

A
  • First choice oral – cefalexin

* First choice IV - cefuroxime

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24
Q

Management of lower UTI - catheterised patients - children <16 - antibiotics?

A

Under 3 months – refer to paediatrics

Over 3 months
o First choice oral
 Trimethoprim, amoxicillin, cefalexin, co-amoxiclav
o First choice IV
 Co-amoxiclav, cefuroxime, ceftriaxone, gentamicin, amikacin

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25
Q

Management of recurrent UTIs - definiton of recurrent?

A

at least 2 episodes within 6 months, or 3 or more within 12 months

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26
Q

Management of recurrent UTIs - when to refer?

A

 Men >16
 People with recurrent upper UTI
 People with recurrent lower UTI when underlying cause unknown
 Pregnant women

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27
Q

Management of recurrent UTIs - general measures?

A

 Non-pregnant women may wish to try D-mannose or cranberry products
 Avoid douching
 Wipe from front to back after defaecation
 Avoid delay in post-coital urination
 Hydration important

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28
Q

Management of recurrent UTIs - antibiotic prophylaxis - men and pregnant women?

A

First choice
o Trimethoprim 200mg when exposed to trigger or 100mg at night
o Nitrofurantoin 100mg when exposed to trigger or 50mg at night

Second choice
o Amoxicillin 500mg when exposed to trigger or 250mg at night
o Cefalexin 500mg when exposed to trigger or 125mg at night
• Review in 6 months

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29
Q

Management of recurrent UTIs - antibiotic prophylaxis - non-pregnant women?

A
  • Vaginal oestrogen (estriol cream) for postmenopausal women with recurrent UTI if behavioural and personal hygiene measures are not effective
  • Can consider single-dose antibiotic prophylaxis or daily antibiotic prophylaxis if needed
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30
Q

When to refer lower UTI to specialist - in women?

A

 Recurrent lower UTI when cause unknown

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31
Q

When to refer lower UTI to specialist - in men?

A

 Ongoing symptoms despite antibiotic treatment
 Suspected bladder outlet obstruction, Hx of pyelonephritis, urinary calculi or previous GU surgery
 Recurrent episodes of UTI (2 or more in 6 months)

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32
Q

Further investigations needed in children with UTI - When to arrange US of UT?

A

 During acute infection in all children with atypical infection:
• Poor urine flow, abdominal/bladder mass, raised creatinine, sepsis, failure to respond to antibiotics within 48 hours, non-E.coli organism
 During acute infection if child <6 months with recurrent UTI
 Within 6 weeks if child >6 months with recurrent UTI
 Within 6 weeks if <6 months with first-time UTI that responds to treatment

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33
Q

Further investigations needed in children with UTI - other tests needed and when?

A

o Dimercaptosuccinic acid scintigraphy (DMSA) carried out within 4-6 months of acute infection if:
 All children <3 years with atypical or recurrent UTI
 All children >3 years or over with recurrent UTIs

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34
Q

Definition of recurrent UTI in children?

A
  • 2 or more UTI with acute pyelonephritis or,
  • 1 episode of acute pyelonephritis + one or more lower UTI with cystitis or,
  • 3 or more UTI with cystitis
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35
Q

When referred to secondary care for UTI - what further tests can be performed?

A

o US KUB
o CT KUB
o Cystoscopy
o Urodynamic studies

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36
Q

Risk factors for pyelonephritis?

A 
o	Women
o	Sexual intercourse
o	Catheter
o	Abnormality of renal tract
o	Antibiotic use
o	Pregnancy
o	Immunocompromise
o	Diabetes Mellitus
o	Spermide
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37
Q

Causative organisms of pyelonephritis?

A

o E. coli in 90% of cases
o Proteus (present under prepuce)
o Klebsiella
o Enterococcus faecalis
o Saprophytic staphylococci (young women)
o Pseudomonas (may indicate structural damage in urinary tract)

38
Q

Symptoms of acute pyelonephritis?

A 
o	UTI symptoms (dysuria, frequency, urgency)
o	Malaise
o	Fever
o	Loin pain +/- back pain
o	Vomiting
o	Rigors
39
Q

Investigations in pyelonephritis?

A
  • Urine dipstick MSU
    o Leukocytes and nitrites, haematuria and proteinuria
  • Urine M, C&S
    o Obtain before starting antibiotics
40
Q

When to refer to hospital - with suspected pyelonephritis?

A

o Septic signs
o Significantly dehydrated or unable to take oral fluids
o Pregnant
o Structural or functional abnormality of GU tract
o Immunosuppression
o Diabetes

41
Q

Management of pyelonephritis - general measures?

A

 Paracetamol for pain
 Increase fluid intake
 Seek medical advice if worsens or does not improve within 48 hours, or person systemically unwell
o Midstream urine sample for M, C & S

42
Q

Management of pyelonephritis - antibiotics - non-pregnant women and men - oral antibiotics?

A

o Oral cefalexin 500mg BD/TD for 7-10 days
o Oral ciprofloxacin 500mg BD for 7 days
o If culture results known:
 Oral Co-amoxiclav 500/125mg TDS for 7-10 days
 Oral trimethoprim 200mg BD for 14 days

43
Q

Management of pyelonephritis - antibiotics - non-pregnant women and men - IV antibiotics?

A 
o	Ceftriaxone
o	Cefuroxime
o	Ciprofloxacin
o	Gentamicin
o	Amikacin
o	Co-amoxiclav (in combination or if culture results known)
44
Q

Management of pyelonephritis - antibiotics - pregnant women - oral antibiotics?

A

o Cefalexin 500mg BD/TD for 7-10 days

45
Q

Management of pyelonephritis - antibiotics - pregnant women - IV antibiotics?

A

o Cefuroxime 750mg to 1.5g TDS/QDS

46
Q

Management of pyelonephritis - antibiotics - children <16 - oral antibiotics?

A

• Under 3 months – refer to paediatric specialist

Over 3 months
 Cefalexin
 Co-amoxiclav (only if culture results available and sensitive)

47
Q

Management of pyelonephritis - antibiotics - children <16 - IV antibiotics?

A 
	Co-amoxiclav (only in combination or if culture result known)
	Cefuroxime
	Ceftriaxone
	Gentamicin
	Amikacin
48
Q

When to review antibiotics in acute pyelonephritis?

A

o Review antibiotics at 48 hours if IV and when cultures available

49
Q

Definition of acute urinary retention?

A
  • Inability to voluntarily urinate
50
Q

Mechanism of acute urinary retention?

A

o Increased resistence to flow
o Inappropriate detrusor muscle innervation
o Bladder over-distention
o Drugs

51
Q

Epidemiology of acute urinary retention?

A
  • Medical emergency, abrupt development of inability to pass urine
  • Common 0.3%
  • Men 10x
52
Q

Causes of acute urinary retention - anatomical?

A 
	BPH (most common)
	Urethral strictures
	Prostate carcinoma
	Prostate haematoma
	Urethral stone
	Foreign body
	Urinary stent occlusion
	Constipation
	Meatal stenosis
53
Q

Causes of acute urinary retention - functional?

A 
	Neurogenic bladder
	MS, Parkinsons, Alzheimer’s, cauda equina syndrome
	SCI
	CVA
	Tumour
	Spinal anaesthesia
	Alcohol
	Pain
	UTI
	Acute prostatitis (E.coli, proteus)
54
Q

Causes of acute urinary retention - drugs?

A

 Anticholinergics, antihistamines, amphetamines, morphine, hyoscine, TCAs

55
Q

Symptoms of acute urinary retention?

A

o Severe pain
o Unable to pass urine
o Previous episodes

56
Q

Signs of acute urinary retention?

A

Tender, distended bladder – dull to percuss above pubic symphysis

57
Q

Initial investigations of acute urinary retention?

A

Rule out cauda equina

Bladder US scan
 Calculates bladder volume

DRE of prostate – after catheterisation
 Check anal tone, prostatic size, nodules, tenderness and exclude faecal impaction

Urinalysis - MSU

Bloods – FBC, U&E, glucose

58
Q

Investigations to perform on ward of acute urinary retention?

A

o Renal US if any renal impairment

59
Q

Immediate management of acute urinary retention?

A

o Catheterisation immediately
 Document post-catheterisation residual volume, type of catheter (14/16G)
o Alpha-blocker given before catheter (tamsulosin)

60
Q

Subsequent management of acute urinary retention?

A

o Treat cause
 If BPH – tamsulosin with finasteride as an adjunct can be used

o Trial without catheter (TWOC) in men with BPH

61
Q

Follow up of acute urinary retention?

A

o If secondary to BPH, constipation, UTI with no previous UT symptoms – no follow up
o Referral to urology clinic

62
Q

Complications of acute urinary retention?

A
  • UTIs
  • AKI
  • Post-retention diuresis, haematuria
63
Q

Physiology of potassium?

A
  • Potassium is mostly intracellular and thus serum potassium is poor indicator of total potassium
  • Concentrations of H and K tend to vary together
  • Insulin and catecholamines stimulate K into cells via Na/K/ATPase pump
64
Q

Normal values of potassium?

A
  • Normal values – 3.5-5mmol/L
65
Q

Classifications of hyperkalaemia?

A

o Mild 5.5-6mmol/L
o Moderate 6.1-6.9mmol/L
o Severe >7.0mmol/L

66
Q

Causes of hyperkalaemia?

A

o Spurious – Haemolysed sample

o Decreased renal excretion – AKI, CKD, K+ sparing diuretics

o Hypoaldosteronism – Addison’s disease, NSAIDs, ACEi

o Cell injury – Crush injury, rhabdomyolysis, burns, incompatible blood transfusion

o K+ cellular shifts – Metabolic acidosis, suxamethonium

67
Q

Symptoms of hyperkalaemia?

A

o Muscle weakness/cramps
o Paraesthesia
o Focal neurological deficits
o Fast, irregular pulse with palpitations

68
Q

ECG changes of hyperkalaemia?

A

o Peaked (tall, tented) T waves
o Small, flat P waves
o Widening QRS complexes (becomes sinusoidal)
o VF

69
Q

When to treat hyperkalaemia immediately?

A

(>6.5 or >6 with ECG changes needs immediate treatment

70
Q

Management of hyperkalaemia - immediate drug management?

A

o 10mL 10% calcium gluconate IVI to stabilise cardiac membrane (up to 30ml if no improvement in ECG)

o 10U soluble insulin (Actrarapid) in 50mL 50% glucose given over 5-15 minutes

o 5mg NEB Salbutamol, repeated once as necessary

o Calcium Resonium 15g orally every 6-8 hours (removes K from GI tract)
 Co-prescribe with lactulose

o Review potassium intake, medications

o Contact renal team – may need dialysis if intractable

71
Q

Definition of hypokalaemia?

A
  • Potassium <2.5 needs urgent treatment but any value under 3.5 considered hypokalaemic
  • Hypokalaemia exacerbates digoxin toxicity
72
Q

Causes of hypokalaemia?

A 
o	Diuretics
o	D&amp;V
o	Cushing’s/Steroids/ACTH
o	Alkalosis
o	Conn’s syndrome
o	Renal tubular failure
o	Pyloric stenosis
o	Intestinal fistula
73
Q

Symptoms and signs of hypokalaemia?

A 
o	Muscle weakness
o	Hypotonia
o	Hyporeflexia
o	Cramps
o	Tetany
o	Palpitations
o	Light-headedness
o	Constipatio
74
Q

ECG changes of hypokalaemia?

A

o Small/Inverted T waves
o Prominent U waves (after T wave)
o Long PR interval
o Depressed ST segments

75
Q

Management of hypokalaemia - mild?

A

 Oral K+ supplement (Sando K tablets) and U&Es daily

76
Q

Management of hypokalaemia - severe?

A

 IV potassium (normal max rate if 10mmol/hr but if severe 20mmol/h) and ensure continuous cardiac monitoring

77
Q

Physiology of sodium regulation?

A
  • Sodium controlled by aldosterone on DCT and collecting duct to increase Na reabsorption from urine
  • Natriuretic peptides ANP, BNP, CNP reduce resorption from DCT and inhibit renin
  • Derangement can occur with hypervolaemia, euvolaemia, hypovolaemia
78
Q

Normal range of sodium?

A
  • Normal ranges – 135-145mmol/L
79
Q

Causes of hypernatraemia?

A

o Diabetes insipidus (lack of ADH or renal response)
o Fluid loss without replacement – Diarrhoea, vomiting
o Osmotic diuretics (mannitol, isosorbide)
o Hypertonic saline
o Cushing’s syndrome

80
Q

Symptoms and signs of hypernatraemia?

A

o Lethargy, thirst, weakness, irritability, confusion and coma
o Signs of dehydration

81
Q

Blood tests of hypernatraemia?

A

o High Na, PCV, albumin, urea

82
Q

Management of hypernatraemia?

A

o Water orally if possible
o If hypovolaemia, 0.9% saline to correct
o Dextrose 5% IV (1L/6h) guided by urine output and serum Na (check every 2-3 hours)

83
Q

Complications of hypernatraemia?

A

o Seizures
o Cerebral/subdural haemorrhages
o Dural sinus thrombosis
o Cerebral oedema

84
Q

Causes of hyponatraemia - if dehydrated?

A

 High urine Na – Addison’s disease, renal failure, diuretic excess, osmolar diuresis

 Low urine Na – Diarrhoea, vomiting, burns, small bowel obstruction, CF

85
Q

Causes of hyponatraemia - if not dehydrated?

A

 Oedematous – Nephrotic syndrome, cardiac failure, liver failure, renal failure

 Not oedematous – SIADH, water overload, hypothyroidism, glucocorticoid insufficiency

86
Q

Symptoms of hyponatraemia?

A

Anorexia, nausea, malaise, headache, irritability, confusion, weakness and seizures

87
Q

Management of hyponatraemia - acute (<24 hours)?

A

Assess volume status

Urine osmolarity
 <100 - primary polydipsia or low solute intake
 >100 and urine sodium >30 & hypovolaemic - vomiting, Addison’s, diuretics, salt wasting
 >100 and urine sodium >30 & euvolaemic - SIADH, secondary adrenal insufficiency, hypothyroid, diuretics
 >100 and urine sodium <30 - heart failure, liver failure, nephrotic syndrome, D&V

Mild
 If hypervolaemic - fluid restriction
 If hypovolaemic - 0.9% saline IV slowly
• Rapid change can lead to central pontine myelinolysis

Na <120mmol/L associated with risk of cerebral herniation
 In emergency consider hypertonic saline (1.8/3%)

88
Q

Management of hyponatraemia - chronic?

A

 Slowly increase Na <10mmol/L per day
 Treat cause
 May need hypertonic saline

89
Q

Definition of hyponatraemia?

A

Mild hyponatraemia — serum sodium 130–135 mmol/L.

Moderate hyponatraemia — serum sodium 125–129 mmol/L.

Severe hyponatraemia — serum sodium less than 125 mmol/L.

90
Q

Classes of hyponatraemia?

A

Acute — hyponatraemia duration for less than 48 hours.

Chronic — hyponatraemia duration for 48 hours or more

91
Q

Complications of hyponatraemia?

A

Life-threatening if severe and/or of acute onset

Swelling of brain cells, cerebral oedema and raised intracranial pressure can lead to seizures, coma, or cardio-respiratory arrest

Increased mortality and longer hospital admission

Chronic hyponatraemia can cause falls, gait disturbances, concentration and cognitive deficits

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