Urology E84-87 Flashcards
- What is Urinary Retention?
It is when urine remains in the bladder. It is characterised by poor urinary stream with intermittent flow, straining and a sense of incomplete voiding and hesitancy.
As the bladder remains full it can cause incontinence, nocturia and high frequency
- Another name for Urinary Retention?
Ischuria
84 Why is acute retention a medical emergency?
Bladder can distend and become painful. Increase in pressure in bladder can cause urine to pass back into ureters and kidneys causing hydronephrosis, kidney failure and sepsis
84 Dx of urine retention?
Cystoscopy, retrograde cystourethrography to evaluate for bladder stones, strictures or tumours
Urodynamic studies such as uroflowmetry, cystometry to evaluate bladder function in patients with neurogenic bladder to help guide management
84 Causes of urine retention?
- Structural\Mechanical: bladder stone in bladder neck, tumour, BPH, Prostate cancer, Foreign body
- Functional (neurogenic) – post op urine retention, injury to the spine, tetanus, certain drugs (anticholinergics)
84 Treatment for urine retention?
Bladder drainage via catherisation can be urethral or suprapubic. Urethral stents can also be used for urethral strictures.prostate medications and surgery
84 What are the different types of catheters?
- Foley: 2 way (irrigation and urine) or 3 way (blood)
- Nelaton – can be straight or curved. Needs to be fixed to skin with tape or suture
84 Which catheter is longer male or female? Why?
Males need longer catheters due to longer urethra
84 How is a suprapubic catheter placed?
- Clean region with iodine and cleaning solution
- Palpate for bladder
- Use local anesthestia
- Make a small incision few inches below the navel
- Insert catheter using stamey device. It has a piece oof metal called obturator to guide catheter
- Remove obturator once catheter in bladder
- Inflate balloon
- Clean insertion area and stich opening
84 Why should you only release 200ml of urine first then wait?
Releasing all the urine in the bladder can risk constriction of vessels leading to haematuria.
84 What is suprapubic drainage?
Suprapubic incision to allow catheter to enter bladder through pelvis and skin.
Typically use cystofix or vesicotomy
85 Definition of urinary incontinence
Involuntaryy leakage of urine. Due to loss or weakened control of bladder
85 What nerve innervates control of urinary sphincter?
hypogastric nerve
85 What is urge incontinence?
Uncontrolled urine leakage moderate to large volume that occurs after urgent need to void. Nocturia and nocturnal incontinence common. Most common in elderly
Men – due to enlarged prostate that cause bladder to drop and irritate urethra
Women – atrophic vaginitis, aging,
85 What is stress incontinence?
Urine leakage due to sudden increase in intra-abdominal pressure (coughing laughing) leakage is low to moderate volume
Men – after procedures like radical proctectomy, stress incontinence more severe in obese due to pressure of abdominal contents
Women – 2nd most common type of incontinence in women, can be due to pregnancy and complications of childbirth, development of atrophic urethritis
85 What is overflow incontinence?
Dribbling of urine from a full bladder. Volume is small but leak can be constant so adds up over time. Occurs when there is an obstruction or blockage to the bladder urinary stones, tumour etc
85 What is functional incontinence?
Urine loss due to congintive or physical impairments (demntia stroke) e.g. pt may not know they need to go or are unable to get to the toilet in time
85 What is Mixed incontinence?
Combination of urge, stress, overflow or functional incontinence. Most common being urge with stress and urge or stress with functional
85 What is gross total incontinence?
Leaks urine continuously or has period of uncontrollable leaking of large amounts of urine can be due to anatomical defect Eg. Fistula from bladder to vagina or spinal cord injury.
85 Risk Factors for urinary incontinence?
Obesity (increased pressure) smoking (chronic cough=increase intraabdominal pressure), age (weak bladder muscles), diseases (spinal cord injury, kidney disease, diabetes, prostate disease)
85 Dx for urinary incontinence?
- Physical exam, urinalysis, blood test (assess kidney function0
- Postvoid residual measurement
- Cystogram – x-ray to visualise bladder, cystoscopy, pelvic ultrasound
85 Tx for urinary incontinence?
Kegel exercises
Bladder training – delaying event to control urge
Double voiding – urinating, wait few mins then go again
Medication
Surgery
Catheter and bag, absorbent pads
85 Medications for urinary incontinence?
Anticholinergics – calm overactive bladder
Topical oestrogen – reinforce tissue in the urethra and vaginal areas and lessen symptoms
85 Surgery tx of urinary incontinence?
Sling procedures – mesh inserted under the neck of bladder to support the urethra and stop leakage
Colposuspension – bladder neck is lifted can help with stress incontinence
Artificial sphincter – artificial sphincter valve can be inserted to control flow of urine from bladder into urethra
86 Def of Urinary obstruction
Blockage of the flow of urine out of the body. Common cause of acute and chronic renal failure
86 Classification of urinary obstruction
Cause – congenital, acquired
Duration – acute, chronic
Degree – partial, complete
Level – upper, lower
86 Causes of urinary obstruction in kids
Urethral and bladder outlet obstruction – urethral atresia, phimosis, meatal stenosis
Ureteral obstruction – vesicoureteral reflux, uretocele, prune belly syndrome
86 Causes of urinary obstruction in adults
Urethral and bladder outlet obstruction – phimosis, stricture, trauma, bph, bladder cancer
Ureteral obstruction – vesicoureteral reflux, inflammatory bowel disease, carcinoma of ureter, uterus, prostate, bladder colon or rectum
Intrarenal obstruction – protein casts, crystals
86 Pathogenesis of urinary obstruction
Upper tract: Ureter: in the early stages intravesical pressure is normal but later the added stretch effect at the lower end of the ureter induces further hydroureteronephrosis. Finally due to the increased pressure the ureteral wall becomes attenuated losing its contractile power at the stage of decompensation.
Mid tract: stage of compensation – bladder musculature hypertrophies
Stage of decompensation – large obstructing gland can be palpated rectally or observed on cystoscopy
Lower tract: obstruction – proximal hydrostatic pressure causes dilation of urethra resulting in thinned urethra walls which then form diverticulum leading to infected urine extravasation resulting in periurethral abscess
86 Symptoms of urinary obstruction?
Reduced flow w/wo pain. Altered patterns of urination, acute or chronic renal failure, haematuria (gross or microscopic), new onset or poorly controlled hypertension
86 Dx of urinary obstruction?
Physical exam urinalysis
Serum electrolytes, blood urea nitrogen creatinine, calcium, phosphate, uric acid, albumin
CT – shows stones etc
MRI
IV pyelography –
Ultrasonography – procedure of choice in determining hydronephrosis
86 Treatment of urinary obstruction
Main aim is the reestablish urinary flow.
Catheter can be placed
Stones are most common cause of unilateral ureteral obstruction can be managed conservatively with small stones. Surgical drainage for patients with severe pain, or persistent obstruction
Extracorporeal shock wave lithotripsy for other stones
pharmacological treatment for bph etc
87 Hydronephrosis Def
Aseptic dilation of whole or part of the kidney due to partial or complete obstruction of urine outflow. Can be bilateral or unilateral.
87 What is hydocalycosis?
Obstruction and dilation of the neck of the calyx
87 Causes of hydronephrosis?
Unilateral:
aberrant renal vessels, involvement of ureter by tumours of cervix, prostate, congenital stenosis at the pelviureteric junction, inflammatory stricture, stone in the ureter
Bilateral:
Congenital – congenital stenosis of urethral meatus or congenital bladder neck
Acquired – bladder neoplasm, retroperitoneal fibrosis, urethral structure or phimosis, BPH
87 Classification of Hydronephrosis
According to flow:
Open, closed or intermitted
According to shape:
Pelvic: when pelvis is extra renal and dilation affects the pelvis more than the kidney
Renal: pelvis is intrarenal and remains small while calyces dilate with atrophy of the renal cortex resulting in rapid destruction of the renal parenchyma
Calyceal: due to obstruction of the calyces
87 Clinical features of hydronephrosis
More predominant in women.
In unilateral cases it is more common in the right side with dull ache or heaviness, can also experience ureteric colic attacks
Bilateral has dull ache in loin
General sx: nausea, vomiting, dysuria, incomplete voiding, fever
87 Dx of hydronephrosis?
Cystourethroscopy for causative lesion in bladder and prostate.
Xray abdo showing calcification, stone or enlargement of renal shadow
87 Treatment of hydronephrosis
Treat the cause ( stone, stricture, tumour, stenosis, ligation of aberrant vessel)
Reconstruction of the pelvis via pyeloplasty, 2 types of pyeloplasty – dismembering and non-dismembering
Nephrectomy for advanced unilateral cases
Indications for surgery attacks ofo renal pain, increasing dilation of pelvis
87 Def of Pyonephrosis
Septic dilation of renal pelvis and its calyces. Kidney full of pus
87 Types of pyonephrosis
Primary = complication of pyelonephritis
Secondary – due to infection of hydronephrotic kidney by blood borne infection
Open or closed
87 Pathology of pyonephrosis
E.coli most common cause. Other causative agents include enterococcus, candida, Klebsiella, pseudomonas, tuberculosis, staphylococcus sp. etc.
Pelvis and calyces are full of pus with mucosal ulceration, parenchyma is atrophied
87 Clinical features of pyonephrosis
Triad of anaemia, fever, swelling in loin. Frequent urination pyuria
87 Dx of pyonephrosis
Urinalysis, urine culture. Xray to show stone or calcification.
Intravenous ultrasonography shows nonfunctioning kidney or delayed function of kidney
87 Tx of pyonephrosis
Removal of obstructive cause with heavy dose antibiotics (gentamicin and ampicillin) clindamycin for anaerobic bacteria coverage
Nephrectomy in advanced unilateral pyonephrosis.
Solitary kidney or bilateral with advanced condition, nephrostomy
