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Revision Year 2 > Urology > Flashcards

Urology Flashcards

1
Q

List 3 common causative organisms of UTI

A

Proteus
Escherishia Coli,
Klebsiella

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2
Q

Systemic factors that predispose an individual to a UTI

A

Immunosuppression
Steroids
Malnutrition
Diabetes

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3
Q

What specific urological problems might lead to an increased risk of UTI?

A

Female sex (short urethra)
Sexual intercourse and poor voiding habits
Congenital abnormalities e.g. duplex kidney
Stasis of urine e.g. due to poor bladder emptying
Foreign bodies eg catheters, stones
Oestrogen deficiency in postmenopausal women
Fistula between bladder & bowel

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4
Q

Describe the typical symptoms & signs of a UTI

A 
Children
Diarrhoea	
Excessive crying
Fever
Nausea and vomiting
Not eating
Adults
*Suprapubic pain
*Dysuria (“like passing broken glass”)
Cloudy *offensive urine
Urgency
Chills
Confusion (very old people)
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5
Q

How are UTIs managed?

A

Mid-stream sample of urine. MSSU
Urinalysis: Blood, Leucocytes, Protein and Nitrites

Microbiology In laboratory
Microscopy and Gram staining
Bacteruria >105 CFU /ml
Culture and sensitivity

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6
Q

Acute Pyelonephritis (Upper UTI)

Chronic Pyelonephritis (Papillary Necrosis)

A 
Pyrexia
*Loin/Flank tenderness (renal angle)
*Signs of dehydration
Turbid/Cloudy/Foamy Urine
White Blood Cell Casts in Urine
Leukocytes in Blood

Scarring & clubbing
Hypertension / CRF

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7
Q

UTI Treatment

A

Fluids
Antibiotics (Amoxicillin, Cephalosporin, Trimethoprim
Severe infections
Intravenous antibiotics

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8
Q

Urolithiasis

A

Men at age 30

Colic Pain
Severe Flank pain / Loin pain radiating to the groin

Urinalysis - Microscopic Haematuria
Ca2+, Albumin, Urate, Parathormone

CT KUB Gold Standard, USS

Commonest Sites of Obstruction: PUJ, Pelvic Brim, VUJ

Rx: Ureteroscopy, Nephrostomy,
Extracorporeal shock wave lithotripsy (ESWL)
Percutaneous Nephrolithotomy (PCNL)

Differentials: Appendicitis, AAA, Testicular Torsion

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9
Q

AKI

A

High Creatinine
Low GFR and tubular function

Pruritus, Rashes, Purpura (blood spots on skin)
Palpitations, High BP
Nausea, Fatigue, Oedema, Encephalopathy

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10
Q

Nephritic Syndrome

Nephrotic Syndrome

A

Haematuria

Proteinuria,

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11
Q

Vesico-Vaginal Fistula

Colo-Vesical Fistula

A

Urinary Leak

Pneumaturia(Bubbles)

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12
Q

Immunosupressive agents after Kidney Transplant

A

Induction Basilixumab

Tacrolimus (AKI, Tremor)
Mycophenolate (Cytopenia)
Steroids

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13
Q

Post Infective Glomerulonephritis

A

10-21 Days after Infection
Genetic Predisposition HLA-DR/DP
Group A Streptococci

Rx: Abx, Loop Diuretics (Frusemide)

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14
Q

Testicular Tumour Markers

A

(AFP) Alfa Fetoprotein - Teratoma
(B HCG) Human Chorionic Gonadotropin - Seminoma
(LDH) Lactate Dehydrogenase - Non - Specific

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15
Q

Hyperkalaemia in ECG

A

1st - T waves Peaked
Widened and Flattened P waves
Broad QRS complexes

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16
Q

Multiple Myeloma Screen

A

Bence Jones Proteins

Serum free light chains

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17
Q

Renal Cell Carcinoma Triad

usually Adenocarcinoma

A

Palpable Mass
Haematuria
Pain Radiating to the back

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18
Q

Bladder Cancer

A

Painless Haematuria

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19
Q

Kidney Cortex

A

Renal Corpuscle =

Proximal and Distal Convoluted Tubule
- Simple Cuboidal Epithelium

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20
Q

RCC common metastasis

A

Lung
Bone - MRI - Spine Compression
Liver

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21
Q

Factors affecting Renin

A

JG Press cell detect decreased pressure; increase reni
Sympathetic activity (b1 efferent)
NaCl delivery at macula densa is inversely proportional
Angiotensin II inhibits renin
ADH inhibits renin release

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22
Q

Hypovolaemia

Decrease in ECF Osmolarity leads to?

Decrease in ECF Volume leads to?

A

ADH Inhibition via osmoreceptors

ADH increase via baroreceptors

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23
Q

Angiotensin II and Na reabsorption

A

Decreased peritubullar cavity hydrostatic pressure increasing Na reabsorption

Aldosterone: Increase Na reabsorption in distal tubule where Macula Densa senses pressure and Na delivery
Tubuloglomerullar Feedback - Constricts afferent arteriole and decreases hydrostatic pressure and GFR

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24
Q

Ang II

A

Arterioles (vasocontriction)

Medulla Oblongata (increased cardio mechanism)

Hypothalamus (Increase ADH, Thirst, Salt retention)

Adrenal Cortex (Increase Aldosterone)

Increase Na and H2O re-absorption

  • Increased Volume
  • Increased Blood Pressure
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25
Q

Aldosterone

A 
Increased Na reabsorption (DT)
                  K Secretion (DT)
                  H2O retention (Weight gain)
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26
Q

Urine flows from the kidneys to the ureters via

A

Peristaltic contraction of ureters smooth muscle

The internal urethral “sphincter” is NOT a true sphincter, but is where the smooth muscle at the start of the urethra acts as a sphincter when the smooth muscle is relaxed.

The external urethral sphincter is a true sphincter, made up of skeletal muscle under voluntary somatic control.

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27
Q

Bladder

A

Overlain with peritoneum
Lies in midline posterior to pubic bones
Lies anterior to reproductive system and rectum
Smooth muscle (Detrusor muscle)
Lined transitional epithelium
Trigone of bladder - 2 vesicoureteric openings
Urethral opening - Vesicoureteric openings
1-2cm oblique passage through muscular wall

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28
Q

Control of Micturition:

Motor innervation:

A

Sympathetic supply (hypogastric nerves)

  • Main function is to prevent reflux of semen into the bladder during ejaculation L1-L3
  • inhibit bladder contraction and closes the internal urethral “sphincter”

Parasympathetic supply (pelvic nerves)

  • contraction of detrusor muscle
  • Pressure within the bladder, S2-S4

Somatic motoneurones (pudendal nerves) - innervate skeletal muscle that forms external urethral sphincter

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29
Q

Sensory Innervation:

A
  1. Stretch receptor afferents from the bladder wall. As the bladder fills. Increase discharge in afferent nerves to spinal cord via interneurones
    a) excitation of parasympathetic outflow
    b) inhibition of sympathetic outflow
    c) inhibition of somatic motoneurones to external sphincter
    d) pathways to sensory cortex  sensation of fullness
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30
Q

ADH functions

A

Controls plasma osmolarity

When the effective OP of the plasma increases, the rate of discharge of ADH-secreting neurones in the SO and PVN increases as well.

Increased release of ADH from the posterior pituitary.

Changes in neuronal discharge are mediated by osmoreceptors in the anterior hypothalamus, close to the SO and PVN.

*Low ECF increases ADH

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31
Q

Respiratory Acidosis

A

Acute: Barbiturates + Opiates
Chronic: Obstructive lung disease
eg bronchitis, emphysema, asthma

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32
Q

Respiratory Alkalosis

A

Voluntary hyperventilation
Aspirin
First ascent to altitude

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33
Q

Metabolic Acidosis

A

Ketoacidosis
Renal failure
Diarrhoea

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34
Q

Metabolic Alkalosis

A

Vomiting (Hypovolaemia - Decreased NaCl)
Aldosterone excess
Excess HCO3-
Massive blood transfusions

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35
Q

PTH

A

Blocks Phosphorus reabsorption in proximal tubule

Increases Calcium reabsorption in distal, collecting tubule and ascending loop of Henle

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36
Q

Increased K+

A

Ventricullar Fibrillation

Aldosterone is released

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37
Q

ECF Buffers

A

Plasma Protein

Diabasic Phosphate

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38
Q

PCO2

pH

[HCO3]

A
  1. 3kPa/40mmHg
  2. 4

24mmmol/l

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39
Q

ECF Osmoles

ICF Osmoles

A

Na, Cl

K+

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40
Q

> Inulin Clearance

< Inulin Clearance

A

Secreted eg. penicillin

Reabsorbed eg.urea

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41
Q

GFR

A

125

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42
Q

Commonest Nephrotic Syndrome in children

A

Minimal Change Disease

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43
Q

Increased Creatinine in renal failure

A

Increased Phosphate

Decreased Calcium

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44
Q

Complicates UTI drugs?

Gram -ve are commonest cause

A

Ciproflaxin
Ceftriaxone
Gentamicin
Co-amoxiclav

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45
Q

Bladder Cancer Management

A

Non-muscle invasive tumours:
Transurethral resection of bladder tumours (TURBT) +
Adjuvant intravesical therapy
(e.g. intravesical immunotherapy with BCG, or intravesical chemotherapy with mitomycin C)

Muscle-invasive tumours:
Cystectomy
Neoadjuvent chemotherapy (e.g. cisplatin)

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46
Q

Incontinence and Urgency

Aetiology, Investigation, Management

A

Weakness of pelvic floor muscles
Overactive Detrusor

Urodynamic Studies eg. Cystometry
-leak point pressure
+Post Void Residual volume with USS

Pelvic floor muscle training (stress UI)
Avoid Stimulants eg Alcohol and Caffeine

Anticholinergic - Oxybutynin

47
Q

Colicky pain in right flank, which radiates to his scrotum

A

Urine Dipstick

  • Haematuria
  • WBC
  • nitrites are a sign of UTI
  • pH urate (acidic), struvite - pseudomonas UTI (alkali)

CT KUB
FBC, U&E

Serum calcium (If high check PTH)
Serum phosphate
Serum urate
(MSSU) microscopy, culture and sensitivity 
24-hour urine collection
48
Q

Renal Stones Treatment

A

Extracorporeal shock wave lithotripsy (ESWL)
Percutaneous nephrolithotomy (PCNL)
Ureteroscopic removal with Holmium laser/lithotripsy
Open surgery

49
Q

Prostate cancer:

A

May be detected at an early stage with PSA screening

May be associated with family history of breast cancer

50
Q

Investigations on the urine sample?

A

Urinalysis – dipstick urine
Urine microscopy, culture and sensitivity
Urine cytology

51
Q

IV Urography contraindications

A

Pregnancy,
Renal insufficiency,
Hypersensitivity to iodine contrast

52
Q

20 years old and haematuria/pain only occurred after a sore throat was is likely diagnosis?

A

IgA Nephropathy (immediately after pharyngitis)

53
Q

54 year old man with known peripheral vascular disease is started on an ACE because of hypertension – ARF
What condition would you wish to consider?

A

Renal artery stenosis

Sx: Renal Bruit, High BP,
Flash Pulmonary Oodema

Ix: Ultrasound / Renal Doppler USS
Intra-arterial angiography
CT or MR angiography

Rx: Renal Balloon Angioplasty and Stenting

54
Q

2 common side effect of B-Blockers?

2 common side effects of Thiazide diuretics?

A

Light-headedness/dizziness
Fatigue

Hyperuricaemia – can precipitate gout
Hyperglycaemia

55
Q

2 common side effects of calcium channel blockers?

1 common side effect of ACEi?

A 
Ankle oedema (swelling)
Postural hypotension

Cough – persistent dry cough

56
Q

4 causes of secondary hypertension?

A

Renal disease – renal artery stenosis, chronic kidney disease, acute GN, APKD

Endocrine disease – cushing’s syndrome,
conn’s syndrome, phaechromocytoma

Pregnancy – pre-eclampsia, eclampsia

Drugs – corticosteroids, oral contraceptive

57
Q

under 55 years of age <

aged 55 or older, >
Any age and African or Caribbean origin

A

ACE inhibitor
Angiotensin-2 receptor blocker (ARB)

Calcium channel blocker CCB

58
Q

Anaemia and Hyperparathyroidism 2ry to KF

Management

A

Recombinant Erythropoietin (EPO)

*Vitamin D analogue (e.g. calcitriol)
+ calcium supplement
(hyperparathyroidism and hypocalcaemia due to Vitamin D deficiency)

59
Q

Polycystic kidneys

A

Cysts in liver – may lead to lLF, and pancreatitis

Berry aneurysms and subarachnoid haemorrhage (SAH)

Mitral Valve Prolapse)

60
Q

Renal Failure Treatments

A

Haemodialysis

Peritoneal dialysis

  • CAPD – continuous ambulatory
  • APD - automated peritoneal dialysis)

Renal transplantation

61
Q

Investigations of underlying cause for renal failure:

A

Blood cultures/stool cultures: infectious diarrhoea?
Arterial blood gas (acidosis)
USS of renal tract: rule out obstruction/hydronephrosis, ?signs of CKD (size/structure)
Urinary sodium levels/urine osmolality: pre-renal vs. renal cause (low in Pre-renal, high in ATN)

62
Q

Nephrotic syndrome

A

Diabetes (diabetic nephropathy) - Slow Proteinuria

Minimal change glomerulonephritis - Children
Very sensitive to *steroid management

Membranous glomerulonephritis - SLE

Focal segmental glomerulosclerosis - ?

Systemic amyloidosis - ?

63
Q

Calculated Osmolarity

A

2 (Na + K) + Glucose + Urea (all in mmol/L)

64
Q

Hyponatraemia Ix

Possible causes of pseudohyponatremia

A

Urine osmolality (>500mmol/kg)

Hypercholesterolaemia
Hyperproteinaemia
Hyperglycaemia

65
Q

Simple UTI Antibiotics

A

Trimethoprim

66
Q

6 months after UTI patient presents with vomiting, rigors, pain and tenderness in the renal angle and dysuria. She is pyrexial and has a tachycardia.
What is the likely diagnosis? and Treatment

A

Acute pyelonephritis

Ciprofloxacin Abx

67
Q

List 5 factors which predispose to UTI?

A 
Female gender
Diabetes mellitus
Pregnancy
Catheterisation
Sexually active
68
Q

Other than UTI, give 4 causes of haematuria

A

Cancer – e.g. renal cell carcinoma, bladder cancer
Renal stone, i.e. urolithiasis
IgA nephropathy
Trauma to urinary tract

69
Q

Causes for
Renal loss of K+:

GI loss of K+:

A 
Diuretics (loop and thiazide) – most common
Renal tubular acidosis (RTA)
Excess aldosterone (e.g. Conn’s syndrome)

Vomiting and diarrhoea
Laxative abuse
Alkalosis

70
Q

loss of K+ Investigations

A

U waves (vs. sine waves for hyper-)
ST depression
Flat T-waves (vs. tented T waves for hyper-)

71
Q

GN IX

Autoantibodies
ANA
cANCA
pANCA

A

Renal Profile (minerals, electrolytes, proteins, glucose)
Blood Film,
ABG, C3+C4
24h-urine collection (protein, creatinine clearance)
Urine Dipstick culture and staining
USS renal tract and Renal Biopsy

SLE
Wegener’s Granulomatosis (AKI)
Vasculitis

72
Q

Nephritic Syndrome Cx and Rx

Nephrotic Syndrome Cx and Rx

A

ARF, CRF
Salt restriction, Fluid monitoring and BP control, Steroids

Hypercoagulability (excess glucose binds with proteins), Hypercholesterolaemia, Infection
Children - Corticosteroids
Diuretics, ACE Inhibitors, Anticoagulation

73
Q

Causes of AKI and Treatment

A

Pre-renal - Hypovolaemia
Sepsis, Renal Artery Stenosis

Renal - Parenchyme
Acute GN, Nephrotoxins, Radiological Contrast

Post-renal - Obstruction to Urine
Prostatic Hypertrophy
Blockage eg. Catheter, Stones, Clots

Rx: Fluid monitoring (CVP line)

74
Q

Dialysis Indications

A 
Pulmonary Oedema
K+ > 6.5mmol/L
pH < 7.2
Pericarditis
Encephalopathy
75
Q

AKI

Serum Creatinine
GFR
Time

A

Risk >90

Injury 60 - 89

Failure 30 - 59

Function is lost 15 - 29

End Stage Kidney Disease < 15 Dialysis

76
Q

Factors affecting GFR

A

afferent and efferent arteriolar diameter

a) Sympathetic VC nerves
b) Circulating catecholamines - constriction 1rily afferent
c) Angiotensin II - constriction, of efferent at [low],
both afferent and efferent at [high]

77
Q

Classic Symptoms of Urinary Tract Infection (UTI)

A

dysuria, urgency, haematuria
Frequency (Passing urine more often in small amounts)
Suprapubic tenderness,
Polyuria (increase volume),
UTI is very unlikely if the urine is not cloudy

78
Q

Pyuria

A

The high presence of pus cells (neutrophil
polymorphs) in urine. Inflammatory response and UTI.

Microscopy of unstained urine (cells, casts or organisms)
>10 white blood cells/mm3 in urine is significant pyuria

79
Q

Bacteriuria

A

The presence of bacteria in urine.

Note that the anterior urethra is not sterile and the presence of urethral organisms in urine washed out during micturition is not bacteriuria.

Causes: Indwelling catheters

Culture and antibiotic treatment should only
be undertaken if the patient is symptomatic
(e.g. feverish, suprapubic pain) and/or shows
signs of infection (e.g. pyrexial, tachycardic,
pyuria in urine specimen).

Screening cultures MSU in pregnancy (increased risk of pyelonephritis and premature delivery),
patients who are undergoing urological surgery or implantation of artificial prosthesis.

80
Q

Cystitis

Acute pyelonephritis

Chronic pyelonephritis

A

Inflammation of the bladder, could be due to infection

Infection of the upper UT involving the kidneys.

Pathological condition with renal scarring and potentially loss of renal function.
Factors which may contribute include diabetes, Infection
vesico-ureteric reflux, and urinary obstruction.
Vague abdominal discomfort + Hypertension

81
Q

UTI Managment

A

any WOMAN with 3 or more symptoms - Abx
only 2 symptoms or fewer, should have (MSU) collected

Urine Dipstick
Nitrite (a metabolic by product of some bacteria)
Protein (sign of inflammation or renal pathology)
Lecucocytes = pus cells (leucocyte esterase - enzyme found in leucocytes - marker of an inflammatory
response)

If not all 3 present follow with urine culture

MEN with suspected UTI should have an MSU
UTI in MEN less common but the incidence increases with age secondary to obstruction caused by
prostatic hypertrophy.

Recurrent UTI in men may be a presenting feature
of prostatitis.

82
Q

Commonest organisms for UTI in MALES

A

Elderly - coliform organisms

In younger males, sexually transmitted organisms such as Chlamydia trachomatis and Neisseria gonorrhoeae

83
Q

Acute Pyelonephritis

A

commonest renal disease

most commonly affects women of child bearing age.

Loin pain and fever, frequency and dysuria less likely

Patients may be systemically unwell,

the causative organism can spread into bloodstream to cause a bacteraemia. - SEPSIS - nausea, vomiting

urine cultured and ABx > aggressive than simple cystitis for at least 7 days
Blood cultures if systemically unwell

84
Q

UTI in children

A

UTI possible diagnosis in any sick child and
every young child with unexplained fever

Follow up is important to identify children with vesico-ureteric reflux as this may lead to renal scarring in later life

85
Q

Risk Factors UTI

A
  1. Short urethra and its proximity to the rectum.
  2. Trauma to female urethra during childbirth.
    - Catheters or Cystoscopy
  3. In pregnancy, increased frequency of acute renal tract
    infection due to stasis of urine (progesterone dilating the ureters and physical pressure from the foetus)
  4. Anatomical abnormalities (e.g. congenital
    pelvi-ureteric junction obstruction,
    vesico-ureteric reflux, duplex kidneys,
    horseshoe kidney, urethral valves,
    prostatic enlargement, chronic urinary retention)
  5. Renal cysts.
  6. Pre-existing renal parenchymal damage
    (e. g. from recurrent pyelonephritis).
  7. Stones in UT, including kidneys, ureter or bladder
  8. Immunosuppression including diabetes
    mellitus, prolonged steroid therapy,
    transplant rejection medications
86
Q

Bacteria Responsible for UTI

A 
E.coli
Proteus sp. *
Enterococcus faecalis
Klebsiella sp. *
Pseudomonas sp. *
  • hospital associated - catheters or instrumentation
87
Q

Sterile pyuria

A

The urine is -ve on culture but significant numbers
of pus cells are present.

collect 3 *morning urines for a ZN stain and TB culture

sign of non-infective pathology in the bladder / kidneys, including renal tract stone disease, interstitial cystitis, urological malignancy, chronic prostatitis

88
Q

Simple cystitis Treatment

A

FEMALES
3-day course
Trimethoprim or Nitrofurantoin / Amoxicillin

Cephalexin if Pregnant

MALES
14-day course 
Trimethoprim or Nitrofurantoin 
OR 
Quinolone (e.g. ciprofloxacin)
to cover possibility of prostatitis
89
Q

Acute pyelonephritis Treatment

A

at least 7 days therapy

ciprofloxacin

90
Q

Lower urinary tract symptoms (LUTS) causes

A

voiding LUTS, storage LUTS, incontinence, polyuria

  • bladder pathology (UTI, interstitial cystitis, bladder cancer)
  • bladder outflow obstruction
    1) Infection/Inflammation - prostatitis, balanitis
    2) Iatrogenic/Trauma - pelvic floor damage after traumatic vaginal delivery or hysterectomy, urethral injury from catheterisation or pelvic fracture
    3) Neoplasia - prostate cancer, penile cancer
    4) Idiopathic - chronic pelvic pain syndrome
    5) Obstruction - primary bladder neck obstruction
    - benign prostatic enlargement (BPE)
    - urethral stricture, phimosis
  • neurological causes (i.e. neurogenic bladder dysfunction):
    i. supra-pontine lesions (stroke, Alzheimer, Parkinson’s)
    ii. infra-pontine supra-sacral lesions
    (e. g. spinal cord injury, disc prolapse, spina bifida)
    iii. infra-sacral (e.g. multiple sclerosis, diabetes, cauda equina compression, surgery to retroperitoneum)
  • systemic disorders (e.g. chronic renal failure, cardiac failure, diabetes mellitus, diabetes insipidus)
91
Q

Kidney Stones RF

A 
Dehydration
hypercalciuria, hyperparathyroidism, hypercalcaemia
cystinuria
high dietary oxalate
renal tubular acidosis
polycystic kidney disease

Drug causes
Loop diuretics, steroids, acetazolamide, theophylline

Thiazides can prevent calcium stones (increase distal tubular calcium resorption)

92
Q

Management of complications related to reduced GFR

A

Acidosis - bicarb
Anaemia – EPO and iron
Bone disease – diet and phosphate binders
CV risk – BP, aspirin, cholesterol, exercise, weight
Death & Dialysis – counsel and prepare
Electrolytes – diet and consider drugs
Fluid overload – salt and fluid restriction, diuretics
Gout – optimise +/- meds
Hypertension – weight, diet, fluid balance, drugs
Iatrogenic issues – BE AWARE

93
Q

Ix of Lower Urinary Tract Symptoms

A

Investigations
MSSU

Flow rate study

Post-void bladder residual USS

Bloods :
PSA
urea and creatinine (if chronic retention)

Renal tract USS if renal failure or bladder stone suspected

Flexible cystoscopy if haematuria

Urodynamic studies in selected cases

TRUS-guided prostate biopsy if PSA raised or abnormal DRE

94
Q

Benign Pro-static Obstruction Tx

A

Medical therapy
Alpha blockers
5 alpha reductase inhibitors (Finasteride or Dutasteride)
Combination

Surgical intervention
TURP Gold Standard **
Open retropubic or transvesical prostatectomy (prostate size >100cc)
Endoscopic ablative procedures

95
Q

Alpha blockers

A

Cause smooth muscle relaxation and antagonise the ‘dynamic’ element to prostatic obstruction

Types :

  • non-selective (alpha 1 and 2) : phenoxybenzamine
  • selective short acting : prazosin, indoramin
  • selective long acting : alfuzosin, doxazosin, terazosin
  • highly selective (i.e. alpha-1a) : tamsulosin
96
Q

5a-reductase converts testosterone to dihydrotestosterone

A
  • Finasteride (5AR Type II inhibitor)
  • Dutasteride (5AR Type I and II inhibitor)
  • reduces prostate size and
    reduces risks of progression of BPE
  • combination therapy of 5ARIs + alpha blockers most effective in reducing risk of progression of BPE
  • can also reduce prostatic vascularity and hence reduces haematuria due to prostatic bleeding
  • potential role in prostate cancer prevention
97
Q

Complications of Bladder Outflow Obstruction

A 
Progression of LUTS
Acute urinary retention
Chronic urinary retention
Urinary incontinence (overflow)
UTI
Bladder stone
Renal failure from obstructed ureteric outflow due to high bladder pressure
98
Q

Chronic urinary retention

A

Painless, palpable and percussible bladder
Patients often able to void but with residuals

Detrusor underactivity which can be 1ry (i.e. primary bladder failure) or secondary (i.e. due to longstanding BOO, such as BPO or urethral stricture)

Presents as LUTS or complications (e.g. UTI, bladder stones, overflow incontinence, post-renal or obstructive renal failure) or incidental finding

Immediate treatment is catheterisation

Cx: Hyponatraemia, Hyperkalaemia, metabolic acidosis, persistent renal dysfunction due to ATN

High pressure 		Low pressure
Painless				Painless
Incontinent			Dry
Raised creatine		Normal creatine
Bilateral hydronephros  Normal kidneys
99
Q

Urinary Tract Obstruction: Presentation

Upper Tract Obstruction

A

Symptoms

  • Pain
  • Frank haematuria

Signs

  • Palpable mass
  • Microscopic haematuria

Complications

  • Infection and sepsis
  • Renal failure
100
Q

Upper Urinary Tract Obstruction

Management

A

Resuscitation

  • ABCs
  • IV access, bloods, ABG, urine, blood cultures
  • fluid balance monitoring
  • IV fluids, broad-spectrum antibiotics
  • Analgesia
  • HDU care +/- renal replacement therapy

Emergency treatment of obstruction
(for unremitting pain or complications)
- Percutaneous nephrostomy insertion OR
- Retrograde stent insertion

Definitive treatment of obstruction - underlying cause

  • stone – Ureteroscopy + laser lithotripsy / ESWL
  • ureteric tumour – radical nephro-ureterectomy
  • PUJ obstruction – laparoscopic pyeloplasty
101
Q

Nephrostomy

A

Percutaneus puncture
!bleeding !adjacent organs
Usually under LA + sedation
US or xray guidance

102
Q

Lower Urinary Tract Obstruction

Management

A

Resuscitation

  • ABCs
  • IV access, bloods, ABG, urine, blood cultures,
  • Fluid balance monitoring
  • IV fluids, broad-spectrum antibiotics (if appropriate)
  • Analgesia
  • HDU care +/- renal replacement therapy

Investigations (imaging: Bladder scan, USS renal tract)

Emergency treatment of obstruction (for unremitting pain or complications)

  • Urethral catheterisation OR
  • Suprapubic catheterisation

Definitive treatment of obstruction

  • Treat underlying cause
  • e.g. BPE – TURP
  • e.g. Urethral stricture – Optical urethrotomy
  • e.g. Meatal stenosis – Meatal dilatation
  • e.g. Phimosis – Circumcision
103
Q

Acute urinary retention

RF, Rx

A

Painful inability to void with a
palpable and percussible bladder

Main risk factor is BPO which can occur spontaneously or triggered by an unrelated event (eg. constipation, alcohol excess, post-operative, urological procedure)

Other RF: UTI, urethral stricture, alcohol excess, post-operative causes, acute surgical or medical problems

Immediate catheterisation (urethral / suprapubic) 
Complications : UTI, post-decompression haematuria, pathological diuresis, renal failure, electrolyte abnorm

If no RF, start a-blocker immediately and remove catheter in 2 days (60% will void successfully); if fail to void, recatheterise and organise TURP (after 6 weeks)

104
Q

Indications for surgery in BPO

A

Progression of LUTS

Acute urinary retention
Chronic urinary retention

Urinary incontinence
UTI
Bladder stone

RF from obstructed ureteric outflow due to
High bladder pressure

105
Q

How long can a short term catheter stay in?

A

Short-term indwelling catheters (up to 2 weeks)

Long-term indwelling catheters (up to 3 months)

106
Q

Major causes of hypokalaemia?

A

Renal loss of K+:
Diuretics (loop and thiazide) – most common

Renal tubular acidosis (RTA)

Excess aldosterone (e.g. Conn’s syndrome)

GI loss of K+: Vomiting and diarrhoea, Laxative abuse

Alkalosis

107
Q

Allantois and cloaca form into

Intermediate mesoderm

Ureteric bud

A

Urinary bladder and urethra

Develops into pronephros (week 4),
Mesonephros in trunk region (week 5 to 9) with a duct and tubules. Duct drains into cloaca

Grows out of the caudal end of the mesonephric duct
and branches to form the renal pelvis, calyces and collecting duct

108
Q

Increase ADH:

Decrease ADH:

A

Pain, emotion, stress, exercise, nicotine, morphine

Alcohol, suppresses ADH release.

109
Q

Factors affecting serum Creatinine:

A

Muscle mass: athletes vs malnutrition

Dietary intake: creatine supplements vs vegetarians

Drugs: Some lead to spurious increases as does ketoacidosis.

110
Q

Normal GFR is approximately

A

100mls/min/1.73m2

111
Q

Voluntary Control of micturation

A

involves descending pathways which:

Stimulate the parasympathetic and:

Inhibit the somatic motor neurones thus summating with the stretch receptor effects

relaxation of the muscles of the pelvic floor and this may cause a sufficient downward tug on the detrusor muscle to initiate its contraction.
Perineal muscles and external sphincter can be contracted voluntarily, preventing urine flow flowing down the urethra or interrupting the flow once urination begins.

After urination, female urethra empties by gravity.
Urine remaining in the male urethra is expelled by contractions of the bulbocavernosus muscle.

112
Q

Operation of the local spinal reflex of micturation

A

As the bladder fills, it becomes distended and the stretch receptors are increasingly stimulated, until their output becomes great enough to cause bladder contraction via:
stimulation of the paraympathetic and:
relax the external sphincter by inhibiting the somatic motoneurones.
In “leaky” babies, the micturition reflex operates at this level because the higher brain connections have to be established. This is also the case in adult patients with spinal cord transection after the initial period of spinal shock.
In an adult the volume of urine in the bladder required to initiate the spinal reflex is  300- 350mls.

113
Q

Abnormalities of Micturition:

A

3 major types due to neural lesions
Interruption of afferent nerves
interruption of both afferent and efferent nerves
interruption of facilitatory and inhibitory descending pathways from the brain.
In all 3 types the bladder contracts but the contractions are generally insufficient to empty the bladder completely and urine is left in the bladder.

Revision Year 2 (14 decks)

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