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UTO Flashcards

1
Q

UTOs are split into upper [5] and lower tract [5]. What causes each?

A

Upper Tract:

  • TCC tumours
  • Stones
  • Blood clots
  • Scar tissue at the PUJ
  • Abdominal/pelvic mass

Lower Tract:

  • Mainly BPH
  • Bladder Stones
  • Phimosis
  • Urethral Strictures
  • Urethral Meatal Stenosis
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2
Q

What are Lower Urinary Tract Symptoms (LUTS)?
Name 4 voiding symptoms
Name 3 storage symptoms
Name 2 other symptoms

A

Lower urinary tract symptoms (LUTS) refer to a group of clinical symptoms involving the bladder, urinary sphincter, urethra and, in men, the prostate.

Split into
Voiding:
- Incomplete Emptying
- Hesitancy
- Poor Stream
- Dribbling

Storage:

  • Frequency
  • Nocturia
  • Urgency/urge incontinence

Other:

  • Intermittency
  • Straining
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3
Q

Whats the difference between acute & chronic urinary retention? [3]
Whats one similarity on examination [1]

A

Acute is a painful inability to void bladder [1]

Chronic is painless incomplete voiding. [1] Chronic may come with progressive LUTS, UTIs or overflow incontinence (bed wetting) [1]

Both have a palpable and percussible bladder.

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4
Q

We’re going to cover 3 types of urinary obstruction

A

Acute lower tract urinary obstruction
Acute upper tract urinary obstruction
Chronic urinary obstruction

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5
Q

Causes of acute lower tract obstruction

A

Intrinsic:

  • Urethral stricture
  • Prolapse
  • Prostatitis
  • Cystitis

Extrinsic

  • BPH
  • Meatal narrowing
  • Phimosis
  • Paraphimosis
  • Balanitis, vaginal lichen planus
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6
Q

Causes of acute lower tract obstruction
Drugs [5]
Neuro [4]

A

Drugs

  • Anti-cholinergic
  • TCA
  • Opioids, BDZ
  • Anti-histamines
  • NSAIDs

Neuro

  • Autonomic neuropathy, DM
  • Guillian barre, pernicious anemia
  • Spinal cord hematoma
  • CES
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7
Q

Presentation of acute lower tract obstruction
Symptoms [2]
Signs [2]
How can acute on chronic urinary retention present? [1]

A

Inability to pass urine
Lower abdominal discomfort

Signs:
- palpable and percussible bladder, enlarged prostate on DRE

Acute on chronic urinary retention can present as overflow incontinence

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8
Q

Acute lower tract obstruction

Investigations [4]

A

• Urinalysis and MC&S
• Bloods:
- U&E, MCS, FBC, CRP, ABG
• Bladder USS

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9
Q 
Explain rationale for each investigation
• Urinalysis and MC&S
• Bloods: 
- U&E, MCS, FBC, CRP, ABG
• Bladder USS
A
  • Urinalysis and MC&S: excl. UTI
  • Bloods: U&E and creatinine (detect AKI), FBC (leucocytosis in infection, low Hb if bleeding), CRP, AVOID PSA, ABG
  • Bladder USS: volume >300cc confirms dx
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10
Q

Mx Acute lower tract obstruction
Immediate management [3]
Management of clot retention [2]

A

Immediate management: ABCDE
o IV access and bloods
o Other immediate mx: IV fluids and abx if septic, analgesia, RRT if required
o Relieve obstruction: urethral or suprapubic catheterisation (if clot retention; require 3 way catheter and bladder washout)

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11
Q

How long do you drain the urine for? How do you know to leave the catheter in place?

A
  • Measure volume drained after 15m: <200 confirms no retention, >400cc confirms catheter should be left in place
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12
Q

Subsequent management

A

Manage underlying cause

Renal USS, check Cr after 12h (AKI)

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13
Q

Subsequent management

  • Urethral stricture
  • Meatal stenosis
  • Phimosis
A

o Urethral structure: optical urethrotomy
o Meatal stenosis: meatal dilatation
o Phimosis: circumcision

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14
Q

Complications [3]

A

post-obstructive diuresis
sodium and bicarb losing nephropathy
Decompression haematuria

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15
Q

What is post-obstructive diuresis and how do you manage it [3]?

A

Massive UO >200ml/hr which can lead to life-threatening hypotension, weight loss and Electrolyte abnormalities

IV fluids resus and then a long term catheter, CISC or TURP.

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16
Q

What is decompression haematuria? [2]

A

Shearing of the small vessles during decompression because of different compliance between different tissue layers.
Usually self-limiting

17
Q

Acute upper tract obstruction

Name 6 causes

A
  • Pelvic-ureteric junction (PUJ) obstruction by scar tissue
  • stone
  • TCC
  • Clot
  • LN mets
  • Abdominal/pelvic mass (tumor/pregnancy)
18
Q 
Acute upper tract obstruction
Symptoms
Describe nature of pain [4]
Triggers [3]
Associated symptoms [2]
Signs [4]
A

Symptoms:
Flank pain: dull, sharp, colicky; restless, radiation to iliac fossa/inguinal area
Provokers: alcohol, diuretics, high fluid intake
Nausea & vomiting
Anuria

Signs:

  • Loin tenderness
  • UTI signs
  • Septic
  • Enlarged kidney rare
19
Q

Investigations [8]

A

Bloods: U&E, Cr, FBC
Urinalysis and MCS
Imaging: renal USS, non-contrast helical CT scan, contrast CT, IV urography

20
Q

Investigations - explain rationale for each

Bloods: U&E, Cr, FBC
Urinalysis and MCS
Imaging: renal USS, non-contrast helical CT scan, contrast CT

A
  • Bloods: U&E and creatinine (AKI), FBC (anaemia of CKD, infection), cultures if sepsis
  • Urinalysis and MC&S: RBC (infection, stones, tumour)
  • Imaging: renal USS (best imaging for unilateral or bilateral hydronephrosis, parenchymal masses), non-contrast spiral CT scan (calculi, level of obstruction)\
21
Q

General management [2] upper tract obstruction

Intervention [2]

A

Nephrostomy
Ureteric stents

Intervention: laparoscopic pyeloplasty for idiopathic PUJ obstruction

22
Q

Complications of ureteric stents [6]

A 
Alpha blocker can reduce ureteric spasm
Stent-related pain
Trigonal irritation
Haematuria
Fever, infection, tissue inflammation if infected calculi
Obstruction, kinking, rupture, migration
23
Q 
Chronic lower tract obstruction
Main etiology [1]
Causes [2]
Presentation [3]
Signs [2]
A 
Main etiology: detrusor inactivity
Causes:
- Bladder outflow obstruction
- Neurological causes
Presentation
- void with residual volumes 400ml to 1L
- Overflow incontinence 
- Renal failure symptoms
Signs:
- Painless palpable + permissible bladder after voiding
- Enlarged kidneys on bimanual
- enlarged prostate on DRE
24
Q

Chronic lower tract obstruction
Investigation
Imaging [5]

A
  • Urinalysis and MC&S
  • Bloods: U&E, FBC, PSA, BM
  • Imaging: urinary tract USS, MRI/CT, post-void residual volumes, urodynamics
25
Q

Investigation - rationale for each

  • Urinalysis and MC&S
  • Bloods: U&E, FBC, PSA, BM
  • Imaging: urinary tract USS, MRI/CT, post-void residual volumes
A
  • Urinalysis and MC&S: detect infection, proteinuria, haematuria
  • Bloods: U&E and creatinine, FBC, blood glucose (DM can lead to osmotic diuresis causing LUTS), PSA
  • Imaging: urinary tract USS (bilateral hydronephrosis), MRI/CT, post-void residual volumes (<50mL = normal, <100mL normal if >65y/o), urodynamics
26
Q

Management [2] chronic outflow obstruction

A

Mx of underlying cause

Clean intermittent self-catheterisation

27
Q

How to differentiate pyelonephritis and pyonephritis (pus in kidney)

Renal (29 decks)

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