Urology Flashcards
causes of urinary tract obstruction
Luminal • Stones • Blood clots • Sloughed papilla Mural • Congenital / acquired stricture • Tumour: renal, ureteric, bladder • Neuromuscular dysfunction Extramural • Prostatic enlargement • Abdo / pelvic mass / tumour • Retroperitoneal fibrosis
presentation of urinary tract obstruction chronic vs acute
Acute • Upper Urinary Tract § Loin pain → groin • Lower Urinary Tract § Bladder outflow obstruction precedes suprapubic pain ¯c distended palpable bladder Chronic • Upper Urinary Tract § Flank pain § Renal failure (may be polyuric) • Lower Urinary Tract § Frequency, hesitancy, poor stream, terminal dribbling, overflow incontinence § Distended, palpable bladder ± large prostate PR
inv and management upper and lower urinary tract obstruction
x • Bloods: FBC, U+E • Urine: dip, MC+S • Imaging § US: hydronephrosis or hydroureter § Anterograde / retrograde ureterograms - Allow therapeutic drainage § Radionucleotide imaging: renal function § CT / MRI Mx Upper Urinary Tract • Nephrostomy • Ureteric stent Lower Urinary Tract • Urethral or suprapubic catheter § May be a large post-obstructive diuresis
complications of ureteric stents
- Infection
- Haematuria
- Trigonal irritation
- Encrustation
causes of urethral stricture
Aetiology • Trauma § Instrumentation § Pelvic #s • Infection: e.g. gonorrhoea • Chemotherapy • Balantitis xerotica obliterans
presentation urethral stricture
Presentation: voiding difficulty • Hesitancy • Strangury • Poor stream • Terminal dribbling • Pis en deux Examination • PR: exclude prostatic cause • Palpate urethra through penis • Examine meatus
inv and management urethral stricture
• Urodynamics § ↓ peak flow rate § ↑ micturition time • Urethroscopy and cystoscopy • Retrograde urethrogram Mx • Internal urethrotomy • Dilatation • Stent
complications of obstructive uropathy
Hyperkalaemia
Metabolic acidosis
Post-obstructive diuresis
• Kidneys produce a lot of urine in the acute phase
after relief of obstruction.
• Must keep up ¯c losses to avoid dehydration.
Na and HCO3 losing nephropathy
• Diuresis may → loss of Na and HCO3
• May require replacement ¯c 1.26% NaHCO3
Infection
causes of urinary retention
• Mechanical § BPH! § Urethral stricture § Clots, stones § Constipation • Dynamic: ↑ smooth muscle tone (α-adrenergic) § Post-operative pain § Drugs
Neurological • Interruption of sensory or motor innervation § Pelvic surgery § MS § DM § Spinal injury / compression
Myogenic
• Over-distension of the bladder
§ Post-anaesthesia
§ High EtOH intake
acute urinary retetioni presetnation and inv
Clinical Features • Suprapubic tenderness • Palpable bladder § Dull to percussion § Can’t get beneath it • Large prostate on PR § Check anal tone and sacral sensation • <1L drained on catheterisation Ix • Blood: FBC, U+E, PSA (prior to PR) • Urine: dip, MC+S • Imaging § US: bladder volume, hydronephrosis § Pelvic XR
management acute urianry retention
Conservative
• Analgesia
• Privacy
• Walking
• Running water or hot bath
Catheterise
• Use correct catheter: e.g. 3-way if clots
• ± STAT gentamicin cover
• Hrly UO + replace: post-obstruction diuresis
• Tamsulosin: ↓ risk of recatheterisation after retention
• TWOC after 24-72h
§ May d/c and f/up in OPD
§ More likely to be successful if predisposing
factor and lower residual volume (<1L)
TURP
• Failed TWOC
• Impaired renal func
presentation of chronic urinary retetntion
entation • Insidious as bladder capacity ↑↑ (>1.5L) • Typically painless • Overflow incontinence / nocturnal enuresis • Acute on chronic retention • Lower abdo mass • UTI • Renal failure
will be high or low pressure (decided on inv)
management of chronic urniary retetnion
High-Pressure • Catheterise if § Renal impairment § Pain § Infection • Hrly UO + replace: post-obstruction diuresis • Consider TURP before TWOC
Low-Pressure • Avoid catheterisation if possible § Risk of introducing infection • Early TURP § Often do poorly due to poor detrusor function § Need CISC or permanent catheter
suprapubic catheterisation
Advantages • ↓ UTIs • Avoids risk of urethral stricture formation • TWOC w/o catheter removal • Pt. preference: ↑ comfort • Maintain sexual function
Disadvantages
• More complex
• Serious complications can occur
Contraindications` • Known or suspected bladder carcinoma • Undiagnosed haematuria • Previous lower abdominal surgery § → adhesion of small bowel to abdo wall
categorise the causes of haematuria
False • Beetroot • Rifampicin • Porphyria • PV bleed
True
General
• HSP
• Bleeding diathesis
Renal • Infarct • Trauma: inc. stones • Infection • Neoplasm • GN • Polycystic kidneys
Ureter
• Stone
• Tumour
Bladder • Infection • Stones • Tumour • Exercise
Prostate
• BPH
• Prostatitis
• Tumour
Urethra • Infection • Stones • Trauma • Tumour
hx and inv for haematuria
Timing? § Beginning of stream: urethral § Throughout stream: renal / systemic, bladder § End of stream: bladder stone, schisto • Painful or painless? • Obstructive symptoms? • Systemic symptoms: wt. loss, appetite Ix • Bloods: FBC, U+E, clotting • Urine: dip, MC+S, cytology • Imaging § Renal US § IVU § Flexible cystoscopy + biopsy § CT/MRI § Renal angio
urinary /kidney stones, who gets them, where
Epidemiology • Lifetime incidence: 15% • Young men § Peak age: 20-40yrs § Sex: M>F=3:1 Pathophysiology • ↑ concentration of urinary solute • ↓ urine volume • Urinary stasis Common Anatomical Sites • Pelviureteric junction • Crossing the iliac vessels at the pelvic brim • Under the vas or uterine artery • Vesicoureteric junction
types of kidney stones
Calcium oxalate: 75%
§ ↑ risk in Crohn’s
Triple phosphate (struvite): 15%
§ Ca Mg NH4 – phosphate
§ May form staghorn calculi
§ Assoc. ¯c proteus infection
• Urate: 5% (radiolucent)
§ Double if confirmed gout
• Cystine: 1% (faint)
risk factors kidney stones
Dehydration • Hypercalcaemia: 1O HPT, immobilisation • ↑ oxalate excretion: tea, strawberries • UTIs • Hyperuricaemia: e.g. gout • Urinary tract abnormalities: e.g. bladder diverticulae • Drugs: frusemide, thiazides
bladder or urethral obstruction
- Bladder irritability: frequency, dysuria, haematuria
- Strangury: painful urinary tenesmus
- Suprapubic pain radiating → tip of penis or in labia
- Pain and haematuria worse at the end of micturition
ureteric colic
eric Colic
• Severe, sudden onset loin pain radiating to the groin
• Assoc. ¯c n/v
• Pt. cannot lie still
inv kidney stones
Urine • Dip: haematuria • MC+S Blood • FBC, U+E, Ca, PO4, urate imaging CT KUB gold standard USS too
preventing kidney stones
Drink plenty
• Treat UTIs rapidly
• ↓ oxalate intake: chocolate, tea, strawberries
treating kidney stones
Analgesia
§ Diclofenac 75mg PO/IM or 100mg PR
§ Opioids if NSAIDs CI: e.g. pethidine
• Fluids: IV if unable to tolerate PO
• Abx if infection: e.g. cefuroxime 1.5mg IV TDS
Conservative: <5mm in lower 1/3 of ureter
• 90-95% pass spontaneously
• Can discharge pt. ¯c analgesia
• Sieve urine to collect stone for OPD analysis
medical management kidney stones
Indications • Stone 5-10mm • Stone expected to pass Drugs • Nifedipine or tamsulosin • ± prednisolone • Most pass w/i 48h, 80% w/i 30d
summarise kidney stones management
initial - pain relief, IV fluids, abx if obs off
if expected to pass but 5-10mm -> nifedipine or tamsulosin +/- pred
if not expected to pass, can do extracorporeal shockwave lithotripsy, percutaneous nephrolithotomy or ureterorenoscopy
procedural interventions kidney stone
Indications
• Low likelihood of spontaneous passage: e.g. >10mm
• Persistent obstruction
• Renal insufficiency
• Infection
Extracorporeal Shockwave Lithotripsy (SWL)
• Stones <20mm in kidney or proximal ureter
• SE: renal injury may → ↑BP
• CI: pregnancy, AAA, bleeding diathesis
Ureterorenoscopy (URS) + Dormier Basket Removal
• Stone >10mm in distal ureter or if SWL failed
• Stone >20mm in renal pelvis
Percutaneous Nephrolithotomy (PNL)
• Stone >20mm in renal pelvis
• E.g. staghorn calculi: do DMSA first
summarise kidney stones management with fever
Febrile + Renal Obstruction
• Surgical emergency
• Percutaneous nephrostomy or ureteric stent
• IV Abx: e.g. cefuroxime 1.5g IV TDS
Rx Summary
• Conservative: stone <5mm in distal ureter
• MET: stone 5-10mm and expected to pass
• Active: stones >10mm, persistent pain, renal
insufficiency
renal cell carcinoma
main RF obestiy, smoing
Adenocarcinoma from proximal renal tubular epithelium • Subtypes § Clear Cell (glycogen): 70-80% § Papillary: 15% § Chromophobe: 5% § Collecting duct: 1%
presentation of RCC
- 50% incidental finding
- Triad: Haematuria, loin pain, loin mass
- Systemic: anorexia, malaise, wt. loss, PUO
- Clot retention
- Invasion of L renal vein → varicocele (1%)
- Cannonball mets → SOB
paraneoplastic features
paraneo features RCC and spread
Paraneoplastic Features • EPO → polycythaemia • PTHrP → ↑ Ca • Renin → HTN • ACTH → Cushing’s syn. • Amyloidosis Spread • Direct: renal vein • Lymph • Haematogenous: bone, liver and lung
