URO - Common Urological Presentations Flashcards
Renal/Ureteric Colic
Pathophysiology
Clinical Features
Investigations
Imaging
Initial Management
1.) Pathophysiology - renal or ureteric stones usually due to over-saturation of urine
- types: calcium (80%), urate (9%), cystine, struvite (stag horn, associated with proteus infection)
- common locations: PUJ, pelvic brim, VUJ
- demographics: male, <65s
- can be caused by type 1(distal) renal tubular acidosis (secondary to RA, SLE, Sjogren’s)
2.) Clinical Features - sudden onset, severe colic pain
- radiating from the flank to pelvis (‘loin to groin’)
- tenderness is not common with renal colic
- haematuria (90% of cases), N/V, restlessness
- most rule out AAA
3.) Investigations
- urine dip and culture: haematuria, rule out infection
- calcium and urate levels
- FBC+CRP (associated infection), U+Es (AKI)
- clotting (if percutaneous intervention planned)
4.) Imaging
- 1°CT-KUB (non-contrast): high sensitivity+specificity
- 2°CT urogram (basically CT-KUB w/ IV contrast): if ^^ is inconclusive
- USS only detects renal stones and hydronephrosis
- AXRs only detects radiopaque stones (not urate)
5.) Initial Management
- stones in lower ureter or <5mm can pass spontaneously within 4 weeks of initial symptom onset
- fluids: reverse dehydration from N/V and ↓intake
- analgesia: PR/IM diclofenac (relaxes the ureters)
- inpatient admission criteria: AKI, uncontrollable pain, infected stone, large stones (>5mm)
Additional Management for Renal/Ureteric Colic
Emergency x2
ESWL
URS
PCNL
1.) Emergency - for infection, pain, hydronephrosis
- JJ stent insertion: temporarily relieves obstruction
- nephrostomy: tube into renal pelvis and collecting system relieves obstruction proximally (favoured in pyonephrosis/infection)
- stone removal not attempted initially due to inflammation
2.) ESWL - extracorporeal shock wave lithotripsy
- targeted sonic waves to break stones (<2cm/20mm)
- performed via radiological guidance
- contraindicated in pregnancy
- cannot be done if stone is in the pelvic brim
3.) URS - flexible uretero-renoscopy
- scope into ureter allowing stones (<2cm/20mm) to be fragmented through laser lithotripsy
- a stent is left in for 4 weeks after
- used instead of ESWL during pregnancy
4.) PCNL - percutaneous nephrolithotomy
- used for only large renal stones (inc staghorn stones)
- stones are fragmented using lithotripsy
- complications: bowel/spleen/liver injury, pneumothorax, sepsis, excessive haemorrhage
Haematuria
Classification
Differential Diagnoses
Clinical Features
1.) Classification
- visible (VH): urine is pink/red/dark brown
- sx non-visible (s-NVH): confirmed on urinalysis or microscopy, presents w/ associated sx e.g. renal colic
- asymptomatic (a-NVH): haematuria w/ no sx
2.) Differential Diagnoses
- infection: UTI, pyelonephritis, prostatitis
- malignancy: bladder, prostate, renal
- renal stones, BPH, trauma, surgery, schistosomiasis, nephritic syndrome
3.) Clinical Features
- total haematuria suggests bladder or upper tract, terminal suggests severe bladder irritation
- associated sx: LUTS, fevers/rigors, suprapubic/flank pain, weight loss, recent trauma/surgery
- hx: DH, smoking status, carcinogens, foreign travel
- abdo exam, DRE, examination of external genitalia
Management of Haematuria
Initial Investigations
Referral Criteria for Haematuria
Specialist Investigations
Management
1.) Initial Investigations
- urinalysis: NVH, infection (leucocytes + nitrites)
- bloods: FBC, U+Es, clotting, PSA
- ACR (albumin:creatinine) in those with deranged renal function or suspected nephrological cause
2.) Referral Criteria for Haematuria
- >45 w/ unexplained VH without a UTI
- VH after successful treatment of a UTI
- >60 w/ unexplained NVH + dysuria or ↑WCC
3.) Specialist Investigations
- flexible cystoscopy (gold), urine cytology
- US KUB for non-visible haematuria
- CT urogram for visible haematuria
4.) Management - treat underlying pathology
- 20% of VH and 5% of NVH have underlying cancer
Lower Urinary Tract Symptoms (LUTS)
Symptoms
Lifestyle Factors
Differential Diagnoses
History and Examinations
Complications
1.) Symptoms
- storage: urgency, nocturia, frequency, incontinence
- voiding: hesitancy, poor flow, terminal dribbling, feeling of incomplete emptying
2.) Lifestyle Factors - can exacerbate symptoms
- drinking at night, excess alcohol/caffeine intake
- polyuria can exacerbate or mimic LUTS
3.) Differential Diagnoses
- prostate: BPH, chronic prostatitis, cancer
- bladder: UTI, cancer, detrusor muscle weakness
- external compression: tumour, faecal impaction
- neurological: MS, spinal cord injury (e.g. CES)
- others: urethral stricture, menopause
4.) History and Examinations
- associated sx: VH, suprapubic discomfort, colic
- DH: can exacerbate LUTS e.g. anti-cholinergics, antihistamines, bronchodilators
- examination: abdomen, DRE, external genitalia
- International Prostate Symptoms Score (IPSS): assesses severity of LUTS and impact on QoL
5.) Complications
- infection, renal/bladder stones (urine stagnation)
- overflow incontinence due to chronic obstruction
- bilateral hydronephrosis and renal failure
- acute urinary retention (due to progressive BPH)
Investigating and Managing LUTS
Initial Investigations
Specialist Investigations
Conservative Management
Pharmacological Management
1.) Initial Investigations
- post-void bladder scan and flow rate (voiding sx)
- urinary frequency-volume chart
- urinalysis: UTI, haematuria, glycosuria (DM)
- bloods: FBC, U+Es, PSA
2.) Specialist Investigations
- cystoscopy (gold): if recurrent infection or haematuria
- urodynamic studies: assesses flow rate, detrusor pressure, storage capacity
- imaging: US or CT
3.) Conservative Management
- regulate fluid intake: timing, volume, types of drinks
- voiding sx: urethral milking, double voiding
- pelvic floor exercises, bladder training techniques
4.) Pharmacological Management
- anticholinergics (oxybutynin): relaxes bladder
- alpha blockers e.g. tamsulosin, finasteride
- furosemide 40mg can be used to prevent nocturia
Acute Urinary Retention
Aetiology
Clinical Features
Investigations
Initial Management
Definitive Management
1.) Aetiology
- BPH (common), urethral strictures, prostate cancer
- UTI: narrows urethral sphincter
- constipation: compresses urethra
- medication: opioids, general anaesthesia, spinal/epidurals, benzodiazepines, anti-cholinergic, anti-histamines, NSAIDs, CCBs, alpha-agonists, alcohol, amitriptyline
- neuro: MS, Parkinson’s, peripheral neuropathy
2.) Clinical Features
- acute suprapubic pain w/ inability to micturate
- associated sx: UTI, recent medication changes, voiding LUTS
- palpable distended bladder w/ suprapubic tenderness
3.) Investigations
- post-void bladder scan: >50ml in <65, >100 in >65s
- bloods: FBC, CRP, U+Es, CSU (urine from catheter)
- US-KUB: if high-pressure retention
4.) Initial Management
- immediate urethral catheterisation
- treat underlying cause e.g. enlarged prostate, infection, constipation, review medication
5.) Definitive Management
- TWOC (trial w/out catheter): success if patient voids successfully w/ minimal residual volume
- multiple failed TWOCs –> long-term catheter
- monitor for post-obstructive diuresis in patients with large retention volume (>1000ml)
Urinary Retention Special Terms
Definition of Acute and Chronic Retention
Acute-On-Chronic Retention
High Pressure Urinary Retention
Post-Obstructive Diuresis
Intermittent Self Catheterisation
1.) Definition of Acute and Chronic Retention
- acute: new onset inability to pass urine leading to pain and discomfort with significant residual volume
- chronic: painless inability to pass urine due to large bladder distension –> bladder desensitization, post void urinary volume is >500ml
2.) Acute-On-Chronic Retention - due to:
- acute deterioration of the underlying pathology
- new cause on top of their chronic retention
- patients may have much higher residual volumes than other acute retention patients
- post catheter urine volume is >800ml
3.) High Pressure Urinary Retention
- pressure high enough to cause hydronephrosis
- high pressure chronic retention can causes permanent renal scarring and CKD
4.) Post-Obstructive Diuresis
- kidneys over-diurese due to loss of medullary conc gradient which can take time to re-equilibrate
- over-diuresis can worsen AKI so urine output monitored over following 24hrs post-catheterisation
5.) Intermittent Self Catherisation
- patients catheterise themselves at regular intervals
- used in patients w/ chronic retention
Pyelonephritis
Risk Factors
Clinical Features
Investigations
Management
Chronic Pyelonephritis
1.) Risk Factors
- ↓flow of urine: obstructed urinary tract (inc BPH), neuropathic bladder (e.g. from SC injury)
- ↑ascent of bacteria: female, indwelling catheters, stents, nephrostomy tubes, structural abnormalities
- immunocompromised: DM, HIV, corticosteroid use
- ↑bacterial colonisation: renal calculi, sex, ↓oestrogen
2.) Clinical Features
- triad: fever, unilateral loin pain, N+V
- may also have sx of LUTI or haematuria
- costovertebral angle tenderness
- important to rule out sepsis or ruptured AAA
3.) Investigations
- bloods, urinalysis (inc ß-hCG), urine culture
- renal USS, CT-KUB if obstruction detected in USS
4.) Management
- A-E assessment, sepsis 6 (if needed)
- antibiotics, analgesia, anti-emetics
5.) Chronic Pyelonephritis
- repeated infections –> fibrosis –> kidney destruction
- more common in urinary reflux caused by:
- strictures (UTIs), vesico-ureteric reflux, anatomical
5 Types of Urinary Incontinence
Stress
Urge
Mixed
Overflow
Continuous
1.) Stress - involuntary leakage of urine due to
- intra-abdominal pressure > urethral pressure
- e.g. coughing, straining, laughing, or lifting
- often due to weakness of pelvic floor muscles so commonly seen in post-partum and post-menopause
2.) Urge - sudden urge to urinate
- overactive bladder (detrusor hyperactivity), causing
↑intravesical pressure –> leakage of urine
- causes: neurogenic (e.g. stroke), infection, cancer, drugs (e.g. AChEi)
3.) Mixed - combination of stress UI and urge UI
4.) Overflow
- complication of chronic urinary retention, where damage to efferent fibres –> loss of bladder sensation.
- causes: BPH (most common), SC injury, congenital
5.) Continuous - constant leakage of urine (always wet)
- due to anatomical abnormality (e.g. ectopic ureter, vesicovaginal fistulae)
- may also be due to severe overflow incontinence.
Management of Urinary Incontinence
Clinical Features
Investigations
Conservative Management
Surgical Management
1.) Clinical Features
- detailed clinical hx to categorise the type
- other sx (dys/haematuria), precipitating factors
- bladder diaries can help work out underlying cause
- QoL questionnaire can help quantify the severity
2.) Investigations
- urinalysis (midstream): infection or haematuria
- post-void bladder scan: overflow UI shows a low post-void residual volume
- PR (BPH), external genitalia (atrophic vaginitis)
- urodynamic assessment if unclear aetiology
- others: abdo exam, cystoscopy, IV urogram, MRI
3.) Conservative Management - first line
- improve oral intake, avoid caffeine, ↑fibre intake
- regular toileting, good bowel habits
- stress/mixed UI: pelvic floor exercises (>3months), duloxetine (SNRI) for stronger urethral contractions
- urge UI: bladder training (at least 6 weeks), anti-muscarincs oxybutynin (should avoid in elderly)
4.) Surgical Management
- urge: botulinum toxin A injections, percutaneous sacral nerve stimulation, augmentation cystoplasty
- stress: tension-free vaginal tape, artificial urinary sphincter, open colposuspension
Priapism
Pathophysiology
Aetiology
Clinical Features
Investigations
Management of Ischaemic Priapism
1.) Pathophysiology - persistent penile erection that lasts for longer than 4 hours and is not associated with sexual stimulation
- ischaemic: impaired vasorelaxation and therefore reduced vascular outflow resulting in congestion and trapping of de-oxygenated blood within the corpus cavernosa
- non-ischaemic: high arterial inflow, typically due to fistula formation often either as the result of congenital or traumatic mechanisms
- bimodal distribution: peaks between 5-10yrs and 20-50yrs
2.) Aetiology
- idiopathic, trauma
- sickle cell disease or other haemoglobinopathies
- drugs: recreational, ED medication, others (anti-hypertensives, anticoagulants…)
- ED medication (e.g. Sildenafil and other PDE-5 inhibitors), this also includes
3.) Clinical Features
- persistent erection lasting over 4 hours, pain localised to the penis
- rare presentation: non-painful erection or an erection that is not fully rigid (both suggestive of non-ischaemic priapism)
- hx of trauma to the genital or perineal region (non-ischaemic priapism)
4.) Investigations - clinical diagnosis
- cavernosal blood gas analysis: ischaemic shows ↓pH, ↓pCO2 and ↑ pCO2
- doppler/duplex US: assess blood flow within penis (blood gas alternative)
- FBC and toxicology screen to assess underlying cause
5.) Management of Ischaemic Priapism - MEDICAL EMERGENCY
- 1°aspiration of blood from the cavernosa w/ a saline flush (remove viscous blood)
- 2°intracavernosal injection of a vasoconstrictive agent such as phenylephrine is used and repeated at 5 minute interval
- 3°consider surgical options
- delayed treatment can lead to permanent tissue damage and long-term ED
- non-ischaemic priapism is normally suitable for observation as a first-line option
