Z Hematuria, Nocturia and Urinary Incontinence Flashcards
Definition of Nocturia
Getting up to urinate > 2 times each night.
Definition of Dysuria
Difficulty urinating, occurring at more external locations such as the urethra, bladder and suprapubic area, or as the urine exits the body.
What 4 factors play a role in age-related delay in urinary excretion?
Fluid intake
Late afternoon/evening intake
Caffeine consumption
Alcohol consumption
What are 2 major causes of peripheral edema, which can worsen nocturnal polyuria?
Venous insufficiency and CHF
Which 5 medications can cause nocturnal polyuria?
Gabapentin
Pregabalin
Thiazolidinediones
NSAIDs
Pyridine CCBs (Nifedipine)
Definition of acute dysuria
Dysuria of less than 1 week’s duration
Definition of internal dysuria
Definition of external dysuria
Dysuria localized to the internal genital structures (urethra, bladder, etc.).
Dysuria localized to the external genital structures (labia majora or minora) as urine leaves the body.
What is the difference between “voiding symptoms” and “storage symptoms”?
Voiding symptoms occur during urination (prolonged termination or urination, dribbling, trouble starting to pee, etc.)
Storage symptoms occur during bladder filling, such as urinary urgency, frequency, nocturia and incontinence.
What is a complicated UTI?
A UTI in patients with functional or structural abnormalities of the UT. These patients have a higher risk for poor treatment outcomes.
Essentials of diagnosis of urinary incontinence include involuntary loss of urine, in addition to stress incontinence, urge incontinence and overflow incontinence.
What are they?
Stress incontinence: leakage of urine upon sneezing, coughing, standing, etc.
Urge incontinence: urgency and inability to delay urination.
Overflow incontinence: unable to empty the bladder. Presentation is variable.
What is the DIAPPERS pneumonic and what is it used for?
It is used to determine transient causes of urinary incontinence.
Delierium Infection Atrophic urethritis and vaginitis Pharmaceuticals Psychological factors Excess urinary output Restricted mobility Stool impaction
What are 3 “established causes” of urinary incontinence?
Detrusor overactivity (urge incontinence)
Urethral incompetence (stress incontinence)
Detrusor underactivity (overflow incontinence)
Detrusor overactivity (urge incontinence) leads to…
It is the most common cause of…
What is detrusor hyperactivity with incomplete contractions (DHIC)?
Overactivity leads to uninhibited bladder contractions that cause leakage.
Most common cause of geriatric incontinence (about 2/3 of cases). It is usually idiopathic.
DHIC is a subtype of urge incontinence that can present with incomplete bladder emptying.
Urethral incompetence (stress incontinence) is caused by…
Which patients are more likely to get it?
What are common causes in men vs. women?
Urethral obstruction.
Older men, rare in older women.
Men: prostatic enlargement, urethral stricture, bladder neck contracture, or prostatic cancer.
Women: cystoceles or other anatomic abnormalities.
What is the least common cause of urinary incontinence?
What causes it?
Detrusor underactivity (overflow incontinence).
Idiopathic or due to sacral LMN dysfunction.
What signs and symptoms are associated with atrophic urethritis and vaginitis? (5)
Vaginal mucosal friability Erosions Telangiectasia Petechiae Erythema
What does the standing full bladder test (asking the pt. to cough while standing) result in with patients with detrusor overactivity?
It will result in a few second delay in release of urine.
In which patients is urethral incompetence seen?
What does the standing full bladder test reveal?
Mostly in women, but can be seen in men following a prostactectomy.
Immediate release of urine.
What is used to distinguish detrusor underactivity from detrusor overactivity and stress incontinence?
What distinguishes detrusor underactivity from urethral obstruction?
An elevated postvoid residual (over 450 mL).
Urodynamic testing.
What lab testing should be done for patients with urinary incontinence?
- UA
2. Check for hyperglycemia, hypercalcemia and DI
What is used to determine postvoid residual?
Ultrasound
What should be done if a patient presents with sudden onset of unexplained urge incontinence (especially if it comes with discomfort or hematuria)? Why?
Cytoscopy and cytologic examination of the urine, because detrusor overactivity can be due to stones or tumors.
What is “the most important aspect from a physician’s point of view” in a patient with BPH?
Symptom management and ensuring there is no evidence of malignancy.
What is LUTS? What causes it?
What are the 2 divisions of LUTS?
Lower urinary tract symptoms that can be a result of BPH and age-related detrusor dysfunction.
The 2 divisions are obstructive symptoms and irritative symptoms.
Asymptomatic patients with BPH do not require treatment, regardless of…
The size of the prostate gland
What detects primary bladder dysfunction?
When is cytoscopy recommended?
Pressure-flow (hemodynamic) studies.
If hematuria is documented and to assess urinary outflow before surgery.
Imagining of the upper UT is recommended under what circumstances? (3)
Hematuria
History of calculi
Prior UT problems
Symptoms from BPH are usually caused by… (2)
Blocked urethra
An overworked bladder from trying to pass urine
What AUA symptom score is associated with mild, moderate and severe symptoms and risk for prostate cancer?
0-7 is mild
8-19 is moderate
20-35 is severe
What are the 3 guidelines will improve PSA screening outcomes in the USA, as opposed to screening solely by age?
- Avoid PSA in men with little to no gain (meaning they are asymptomatic with a low life expectancy. Test men > 75 y/o only in special circumstances).
- Do not treat men who are asymptomatic. Many patients with prostate cancer do not need immediate treatment and can be surveilled.
- Refer men who do not need treatment to a urologist.
Are DRE and PSA recommended in routine screening?
How should a patient’s risk for BPH and prostate cancer be determined?
For men with a PSA of 4-7 ng/ml with a significant symptom score, what should be done?
NO.
It should be determined without a DRE and PSA.
Urology referral.
What is the difference between a diagnosis of UTI vs. asymptomatic bacteriuria (ASB)?
Both have bacteria and WBCs in the urine, but ASB occurs in the absence of symptoms attributable to the bacteria in the UT and does not need treatment. UTI typically warrants ABX.
UTI denotes symptomatic disease, such as… (2)
Cystitis and/or pyelonephritis
What us an uncomplicated UTI?
Acute cystitis or pyelonephritis in a non-pregnant women without anatomic abnormalities.
Catheter-associated bacteruria (CAUTI) can be either…
Symptomatic or asymptomatic
Asymptomatic bacteruria (ASB) is usually diagnosed when?
Does it ever come with systemic symptoms?
Diagnosed when a pt. undergoes a UA for a reason unrelated to the GU tract.
Symptoms like fever, altered mental status, leukocytosis, etc. can be present, but may be due to other current problems and don’t warrant a diagnosis of UTI.
What are symptoms of cystitis? (4)
What symptoms suggests a systemic infection (including the bladder)?
What is unique about the presentation of cystitis in elderly patients?
Nocturia, hesitancy, suprapubic discomfort, and gross hematuria.
Fever.
Elderly patients may present without a fever, which makes diagnosis and therapy hard to determine.
What is the main distinguishing feature of pyelonephritis and cystitis?
When do symptoms onset in pyelonephritis?
Fever is more common in pyelonephritis.
Acute onset.
What symptomatic “pattern” is associated with pyelonpehritis?
How often does bacteremia occur?
What suggests bilateral papillary necrosis in these patients?
“Picket-fence”, as in the symptoms come and go.
20-30% develop bacteremia.
Rapid increase in serume [creatinine].
What is emphysematous pyelonephritis?
When is it found?
A severe form that is associated with gas in the renal and perinephric tissues in patients with DM.
It is found via US when a retroperitoneal abscess is suspected.
What is xanthogranulomatous pyelonephritis?
What is seen on pathology?
Pyelonephritis due to chronic urinary obstruction (calculi), together with chronic infection, which leads to suppurative destruction of renal tissue.
The residual renal tissue is yellowish with infiltrating lipid-laden macrophages.
What can complicate pyelonephritis?
When should it be suspected?
Intraparenchymal abscess formation.
When a patient has continued fever and/or bacteremia despite ABX therapy.
Is prostatitis infectious?
Is it acute or chronic?
What is the cause, usually?
It can be, but not always.
Can be either.
Usually bacterial.
What are some symptoms of acute prostatitis?
Dysuria, frequency and pelvic pain.
Fever and chills are common.
Pt. will often complain of pressure or pain in area between scrotum and anus. It may manifest as trouble sitting for a long time.
What usually precedes chronic prostatitis?
Recurrent episodes of cystitis
How does heart failure contribute to nocturia?
HF can lead to poor renal perfusion during the day when the patient is upright, which normalizes at night while the patient is lying and lead to diuresis.
What are the 3 essential to diagnosing urinary stone disease?
Sever flank pain
N/V
Non-contract CT or US
Who is more likely to develop urinary stone disease?
When is incidence greatest?
M > F (2.5:1) in their 20s-30s.
During the summer.
What causes hypercalciuric calcium nephrolithiasis?
Absorptive, resorptive and renal disorders
What causes hyperuricosuric calcium nephrolithiasis?
It occurs secondary to dietary excess of uric acid or metabolic defects of breaking it down.
What causes hyperoxaluric calcium nephrolithiasis?
It occurs due to primary intestinal disorders, like chronic diarrhea, IBD or steatorrhea.
What causes hypocitraturic calcium nephrolithiasis?
It occurs secondary to disorders associated with metabolic acidosis (diarrhea, RTA - type 1, long-term HCTZ therapy, etc.)
What are contributing factors to uric acid calculi? (5)
Low urinary pH Myeloproliferative disorders Malignancy with increased uric acid levels Abrupt weight loss Uricosuric medications
What causes struvite calculi?
Recurrent UTIs with urease-producing organisms (*Proteus, Pseudomonas, Providenica, etc.)
What causes cystine calculi?
It is an inherited disorder with recurrent stone disease.
What types of stones are indicated at the following urinary pH levels?
< 5.5
> 7.2
5.5 < X < 6.8
< 5.5 - uric acid or cystine stones
> 7.2 - struvite stones
5.5 < X < 6.8 - calcium-based stones
What is used to diagnose most stones?
What is most accurate in evaluating flank pain?
KUB and/or US
Spiral CT
What are the essentials to diagnosing acute bacterial prostatitis? (5)
Fever Irritative voiding symptoms Perineal or suprapubic pain Tenderness on DRE Positive urine cultures
Most common causative organisms in acute bacterial prostatitis… (2)
E. coli and Pseudomonas
What are some symptoms of acute bacterial prostatitis?
Perineal, suprapubic or sacral pain Fevere Irritative voiding complaints Urinary retention Tender prostate
In acute bacterial prostatitis, what will the results be of a CBC, UA and urine cultures?
CBC - Leukocytosis with a left shift
UA - pyuria, bacteruria, hematuria
Cultures - positive
What meds can be given for acute bacterial prostatitis? (5)
IV ampicillin and aminoglycoside Ampicllin Cipro Ofloxacin Trimethoprim-sulfamethozole
In patients with DM, what is the cause of nocturia?
Elevated glucose leads to osmotic diuresis.
How do you determine if a patients has hemoglobinuria or myoglobinuria? What do each of these suggest?
If, after centrifuge, there is no red sediment with RBCs on microscopy, but the supernatant is positive for Hb by urine dipstick.
Hemoglobinuria: intravascular hemolysis
Myoglobinuria: nreakdown of skeletal muscle
What is gross hematuria?
How many blood cells per high-powered field exist?
Presence of blood in urine that is visible by the naked eye. After centrifuge, red sediment with RBCs will be seen on microscopy.
> 3500 RBCs/field
How many blood cells per high-powered field exist in microscopic hematuria?
2-3 RBCs/field
When is a referral to nephrology or urology recommended in a patient with hematuria?
Even after a single episode, unless it has an easily attributable cause (trauma, infection, menses, etc.).
What is the difference between glomerular and non-glomerular causes of hematuria?
Glomerular causes are the glomerulonephropathies. Non-glomerular include things like stones, cystitis, BPH, etc.
Alarm symptoms associated with hematuria include… (4)
Increasing age
Constitutional symptoms
Risk factors for malignancy (smoking, exposure, etc.)
Family history of renal disease or deafness (Alport syndrome)
What are 2 common causes of transient microscopic hematuria?
When would the hematuria be likely to resolve?
UTIs and strenuous exercise
Approx. 2-3 days
What are 2 “spurious” causes of microscopic hematuria in women?
Menstruation and sex
All patients with hematuria should have what test done?
Urine cultures
What differentiates glomerular and non-glomerular hematuria?
Glomerular hematuria is more likely to include dysmorphic RBCs (acanthocytes), red cell casts, new/worsening HTN or proteinuria and increased creatinine.
Visible blood clots are never due to ___________.
Glomerular injury
Triad of symptoms in renal cell carcinoma
Hematuria
CVA pain
Flank mass
Constitutional complaints
What syndrome is associated with renal cell carcinoma?
VHL syndrome
Tumors confined to the renal capsule (T1-2) have a 5-year disease-free survival of:
Tumors extending beyond T3-4 have a 5-year survival of:
Tumors with mets to nearby lymph nodes have a 5-year survival of:
Patients with solitary resectable mets have a 5-year survival of:
90-100%
50-60%
0-15%
15-30%
IgA nephropathy commonly presents as…
What is the outcome of IgA nephropathy?
Episodic gross hematuria with URIs.
40% will reach ESRF after 20 yrs.
What pathologic features are seen in IgA nephropathy?
MEST
Mesangial hypercellularity
Endocapillary hypercellularity
Segmental glomerulosclerosis
Tubular atrophy/interstitial fibrosis
What confers a good prognosis in IgA nephropathy?
When should patients get a biopsy?
Normal renal function and low proteinuria
Sustained proteinuria > 1 g/day or worsening kidney function
When is medullary sponge kidney diagnosed?
What mutations are involved?
It is present at birth, but is diagnosed in 30s-40s.
AD inheritance of MCKD1 or MCKD2 genes on chromosomes 1 and 16.
What is the presentation of medullary sponge kidney?
How do the kidneys look grossly?
Hematuria, recurrent UTIs, or nephrolithiasis.
Irregular enlargement of the medullary and interpapillary collecting ducts.
What imaging is best for medullary sponge kidney?
CT urography
Patients with medullary sponge kidney may often exhibit… (2)
Reduced kidney concentrating ability and increased frequency of UTIs
Overall, medullary sponge kidney is considered to be a _________ disorder.
Benign disorder
