#7. Urolithiasis - Complications & Treatment, Inflammatory Diseases of Urinary System, Pyelonephritis, Urosepsis

Question 1

What are the Obstructive Complications of Urolithiasis?

Answer 1

1) HydroCALYCOSIS = Stone in Neck of Calyx preventing Urine Outflow

2) HydroNEPHROSIS = Stone in Pelvis / Pyelo-ureteral Segment

3) URETERIC Hydronephrosis = Stone in DIFFERENT Location of Ureter

4) Urinary Retention = Calculus Obstruction in Bladder Neck / Urethra

5) Oliguria & Anuria = Obstructive Calculus Anuria of Single Kidney / Bilateral Lithiasis

Question 2

What are the Inflammatory Complications of Urolithiasis?

Answer 2

1) Chronic Pyelonephritis / Cystitis = Chronic Inflammatory Process at the Site of Stone

2) Acute Calculous Pyelonephritis = Aka Obstructive Calculous Pyelonephritis

3) APOSTEMATOUS Pyelonephritis = Multiple Miliary Purulent Foci in Subcapsular Space

4) Kidney Abscess = 1 or More Purulent Cavities in Parenchyma of Kidney

5) CARBUNCLE of Kidney = Area filled with pus with surrounding necrotic tissue

6) PERI-nephritis = Inflammation of Kidney Capsule

7) PARA-nephritis = Inflammation of PERINEAL FAT Capsule

8) Para-NEPHRIC Abscess = Purulent Foci in PERINEAL Space

9) XANTHOGRANULOMATOUS Pyelonephritis = Chronic GRANULOMATOUS Process of Kidney due to Subacute / Chronic Infection inducing Immune Response

Question 3

What is the Medication for Renal Colic?

Answer 3

• 1st Line = NSAIDs 150mg / Day for 3 - 10 Days E.g. DICLOFENAC
• 2nd Line = Spasmolytics + Analgesics (Orally) E.g. PAPAVERIN
• 3rd Line = NON-Narcotics / Opioid Analgesics (Parenterally)

Question 4

What is Medical Expulsive Therapy?

Answer 4

• They’re CONSERVATIVE Methods contributing to the ELIMINATION of the Stone (Small Ones)

Question 5

What is the Principle of Operation of Extracorporeal Lithotripsy Devices?

Answer 5

• Modern Shock Wave Generating Devices use Electromagnetic Generators
• Lithotripter breaks up the stone with focused, high-energy waves impacting the HETEROGENOUS Structure of the Stone

Question 6

What are the Indications for Extracorporeal Lithotripsy?

Answer 6

• Radiopaque Stones UPTO 15mm
• NO Inflammatory Complications from Kidney Stone Disease
• ABSENCE of URETERAL Strictures / Congenital Anomalies of PYELOURETERAL SEGMENT

Question 7

What are the Complications Following Extracorporeal Lithotripsy?

Answer 7

• Subcapsular Renal Hematoma
• Rupture of Kidney

Question 8

What are the Methods of Intracorporeal Lithotripsy?

Answer 8

• Retrograde Ureteroscopy
• Percutaneous Nephrolithotomy

Question 9

What are the Indications for Percutaneous Nephrolithotomy?

Answer 9

• Minimally Invasive Surgery to REMOVE Kidney Stones
• An ALTERNATIVE to OPEN Kidney Surgery

Question 10

What Advice would you give to patients with Urolithiasis to reduce Stone Formation?

Answer 10

• Balanced Diet
• RICH in Vegetables / Fibre
• Normal Calcium Content = 1 - 1.2 g / Day
• NaCl Content = 4 - 5g / Day
• Animal Protein Content = 0.8 - 1 g / Day

Question 11

What are the Most Common Uropathogens?

Answer 11

• E.Coli and Coliforms
• Gram POSITIVE Microorganisms
• Polymicrobial Infections (Adults)

Question 12

Which Infections are Classified as Uncomplicated and which as Complicated?

Answer 12

1) Uncomplicated Infections
- Cystitis
- Pyelonephritis
- Recurrent UTI
- Urosepsis (LOW Risk)

2) Complicated Infections
- Cystitis
- Pyelonephritis
- Recurrent UTI
- Catheter Associated UTI
- UTI in Men
- Urosepsis (HIGH Risk)

Question 13

What is the Definition of Recurrent Infection?

Answer 13

• 2 Episodes within 6 Months
• 3 Episodes within 1 Year

Question 14

In Which Patients does Asymptomatic Bacteriuria NOT benefit from Treatment?

Answer 14

In PREGNANT Women

• Due to INCREASED Progesterone / Residual Urine Volume
• DUE to Delayed Peristalsis / Urinary Retention in Upper UT / Uterine ENLARGEMENT
• EASILY FORM into SYMPTOMATIC Infection with Potential HARMFUL EFFECTS on the FOETUS

Question 15

In Which Patients is it Recommended to Treat Asymptomatic Bacteriuria?

Question 16

In Different Age Groups, what are the most common causes of Urinary Tract Infections?

Answer 16

• LESS than 1 Years = DUE to Anatomic Genitourinary Abnormalities
• Ages 1 - 5 = DUE to Anatomic / Functional Genitourinary Abnormalities
• Ages 6 - 15 = DUE to Functional Genitourinary Abnormalities
• Ages 16 - 35 = Sexual Intercourse / Diaphragm Use
• Ages 36 - 65 = DUE to Surgery / Prostate Obstruction / Catheterisation
• MORE than 65 Years = DUE to Incontinence / Catheterisation

Question 17

What are the Symptoms of Patients with Cystitis?

Answer 17

• Dysuria
• Frequency / Urgency
• Low Back / Suprapubic Pain
• Haematuria
• Cloudy / Smelly Urine

Question 18

What is the Treatment for Acute Cystitis?

Answer 18

• 3 Day Course of TRIMETHOPRIM / SULFAMETHOXAZOLE (TMP / SMX)
• 5 Day Course of FOSFOMYCIN as SINGLE Dose

Question 19

What Recommendations would you make for Patients with Recurrent Cystitis?

Answer 19

• FLUROQUINONES can be used for TMP / SMX Resistance

Question 20

What are the Symptoms of Acute Pyelonephritis?

Answer 20

Symptoms of LOWER UT
- Frequency of Urination
- Urgency of Urination
- Discomfort in Urethra
- Nausea / Vomiting

Question 21

How is Chronic Pyelonephritis Diagnosed?

Answer 21

• Intravenous Urography
• CT

SHOWS Small + ATROPHIC Kidney on AFFECTED Side

Question 22

Which Disease is Considered in Differential Diagnosis of Xanthogranulomatous Pyelonephritis?

Answer 22

• MISTAKEN for RENAL Cell Carcinoma (RCC)

Question 23

What are the Risk Factors for Emphysematous Pyelonephritis?

Answer 23

• Diabetes Mellitus
• Escherichia Coli, as Microbial Causative Agent

Question 24

What is the Difference Between Bacteremia and Sepsis?

Answer 24

• Bacteremia = Presence of BACTERIA in BLOODSTREAM
• Sepsis = INFECTION that has SYSTEMIC Manifestation E.g. SIRS

Question 25

What are the Criteria for Systemic Inflammatory Response Syndrome?

Answer 25

AT LEAST 2 of the Symptoms

• RISE / FALL in Temperature
• Tachycardia MORE than 90bpm
• Tachypnea of 20x per Minute
• Leukocytes MORE than 12,000 or 4,000 / cubic mm

Question 26

What are the Risk Factors for Urosepsis?

Answer 26

• Foreign Bodies (Catheters / Nephrostomy)
• Instrumental Examinations of Excretory System
• Diabetes
• Immunosuppression
• POST-Chemotherapy

Question 27

What are the Most Common Lab Abnormalities in Patients with Sepsis?

Answer 27

• CBC = INCREASED / DECREASED N.O of Leukocytes + DECREASED Platelets
• Coagulation Status = INCREASED INR > 1.5 / apTT MORE than 60 sec
• ELEVATED Urea / Electrolytes
• Hourly Urine = LESS than 0.5 ml / kg/ h FOR 2 hours (Organ Dysfunction)

Question 28

What are the Principles in the Treatment of Sepsis?

Answer 28

1) Antimicrobial Treatment = Cephalosporins / Meropenem / Imipenem / Cilastatin WITHIN 1st Hour

2) Source Control = Nephrectomy / Orchiectomy

3) Supportive Therapy = O2 / Electrolytes / Normoglycemia (Diabetics) / PREVENTING Thrombosis