Urology Flashcards
What are some causes of haematuria?
Infection
Malignancy
Renal calculi
Trauma
What should be asked about in a history for haematuria?
Associated sx - suprapubic pain, fever, flank pain
Smoking
Drug history
Occupational history - industrial carcinogens
Travel history - schistosomiasis
What are the initial investigations for haematuria?
Urine dip
Bloods - FBC, U&Es, clotting, PSA
Deranged renal function => urine protein levels
When should someone be referred for haematuria?
> 45yrs with visible haematuria no evidence of UTI, or visible which persists after tx for UTI
60yrs non-visible haematuria w/ dysuria/raised WCC
Nephrological cause, falling GFR, CKD, proteinuria, <40yrs with HTN
What are renal stones typically comprised of?
Calcium oxalate/phosphate
Struvite - typically staghorn calculi
Cysteine
Urate
Where are renal stones likely to be located?
Narrow points
Pelviureteric junction, crossing the pelvic brim, vesicoureteric junction
How do renal stones present?
Sudden onset loin to groin pain Colicky due to peristalsis Nausea and vomiting Haematuria Signs of infection
What initial investigations are done for ureteric colic?
Urine dip - blood, signs of infection
Bloods - FBC, CRP, U&E, urate and calcium levels (stone composition)
What imaging is done for ureteric colic?
Non-contrast CT KUB - identify stone, assess for alternative pathology
USS - assess for hydronephrosis
What is the initial management for ureteric colic?
Fluid resuscitation
Analgesia - opiate/NSAIDs PR
IV abx if signs of infection
Should pass spontaneously if <5mm
When should someone with renal stones be admitted?
Stone >5mm
Uncontrolled pain
Evidence of infection
Post-obstructive AKI
What is the management for ureteric stones => obstructive uropathy/significant infection?
Stent insertion via cystoscopy
Nephrostomy
What is the definitive treatment for ureteric/renal stones?
Extracorpeal shock wave lithotripsy - for small stones, stone broken up by shock waves
Percutaneous nephrolithotomy - renal stones only, fragmented via lithotripsy
Flexible uretero-renoscopy - laser lithotripsy => fragments then removed
What are complications of ureteric/renal stones?
Infection
AKI
Recurrence => scarring and loss of kidney function
What advice should be given for specific stones?
Calcium - check PTH levels
Urate - avoid red meat, may need allopurinol
Cystine - genetic testing, homocystinuria
What are different types of incontinence?
Stress Urge Mixed Overflow Continuous
What is stress incontinence?
Leakage of urine when intra-abdominal pressure exceeds urethral pressure
Due to weakness of the pelvic floor muscles
What are risk factors for stress incontinence?
Post-partum damage to pelvic floor muscles and urethral sphincter
Constipation, obesity, post-menopausal
What is urge incontinence?
Detrusor hyperactivity => overactive bladder
Uninhibited bladder contraction => rise in intravesicular pressure => leakage of urine
What are causes of urge incontinence?
Neurogenic eg stroke
Infection, malignancy, idiopathic
Drugs eg cholinesterase inhibitors (used to treat Alzheimer’s; donepezil, rivastigmine)
What is overflow incontinence?
Progressive stretching of bladder wall => loss of bladder sensation
Loss of ability to identify the need to urinate => build up of pressure and dribbling of urine
What causes overflow incontinence?
Chronic urinary retention
Prostatic hyperplasia, spinal cord injury
What initial investigations should be done for incontinence?
Urine dipstick - infection, haematuria
Post-void bladder scan
How are urodynamics used to assess incontinence?
Measure intra-vesicular and intra-abdominal pressure, allows measurement of detrusor muscle pressure => suggests urge incontinence
What do outflow urodynamics assess?
Measures detrusor muscle activity against urine flow rate
High intra-vesicular pressure with poor urine flow => overflow
What lifestyle advice should be given for incontinence?
Weight loss, reduce caffeine intake, smoking cessation
How can stress incontinence be managed?
Pelvic floor muscle training
If not responsive/unsuitable for surgery => duloxetine can be trialled => stronger urethral contractions
How can urge incontinence be managed?
Bladder training for at least 6 weeks
Anti-muscarinic drugs eg oxybutinin/tolterodine
What are causes of acute urinary retention?
BPH, prostate ca, urethral strictures
Constipation
Neuro causes - peripheral neuropathy, MS, Parkinson’s
Drugs - anti-muscarinics, spinal/epidural anaesthesia
How does acute retention present?
Inability to pass urine, suprapubic pain
Signs of infection
Recent change to meds
Palpable bladder, may have an enlarged prostate
What investigations are done in acute retention?
Post void bladder scan - shows volume of retained urine
Bloods - FBC, CRP, U&Es
Need to send off CSU
USS to look for hydronephrosis
How is acute retention managed?
Catheter, measure amount drained
Treat underlying cause
BPH - tamsulosin
Signs of infection - abx
What are complications of acute retention?
AKI, hydronephrosis
High pressure urinary retention
Post-obstructive diuresis
What is high pressure urinary retention?
High intra-vesicular pressure overcomes the anti-reflux mechanism of bladder
Urine backs up into ureters => hydronephrosis/hydorureter
Deranged renal function
What is post-obstructive diuresis?
Kidneys over-diurese post catheterisation due to loss of medullary conc
Leads to worsening AKI
If producing >200ml/hr should have ~1/2 of their urine output replaced
