Haematuria (urology) Flashcards
(153 cards)
1
Q
Define AKI
A
Sudden deterioration in kidney function
2
Q
NICE specifications for presence of AKI
A
- urine output <0/5ml/kg for 6 hours
- > 50% rise in creatinine over 7 days
- 26 micromol rise in creatinine over 48 hours
3
Q
Serum creatinine and urine output in AKI stage 1
A
Serum creatinine: 150-200% increase or 25 umol/l increase in 48h
Urine output: <0.5ml/kg/h for 6h
4
Q
Serum creatinine and urine output in AKI stage 2
A
Serum creatinine: 200-300% increase
Urine output: 0.5 ml/kg/h for 12 h
5
Q
Serum creatinine and urine output in AKI stage 3
A
Serum creatinine: >300% increase or >350umol/l with acute rise of >45umol/l in 48h
Urine output: <0.3ml/kg/h for 24h or anuria for 12h
6
Q
What is pre-renal AKI
A
Occurs when the blood supply to the kidney is interrupted
2 causes:
- shock : hypovolemic, cardiogenic, distributive
- renovascular obstruction: aortic dissection, renal artery stenosis, ACEi
7
Q
What is acute tubular necrosis
A
Prolonged interruption to the blood supply ischaemia leads to necrosis of the cells that line the renal tubules
- leads to porous tubular membranes and also blockage of the tubules by necroses cells
- urine is isotonic with plasma and has high sodium as concentrating powers are lost
8
Q
What is post renal AKI
A
Occurs when there is obstruction to the outflow of the urinary tract
Leads to back flow of urine, damage to the kidney architecture and resultant organ failure
Blockage is often in the ureters
9
Q
3 causes / mechanisms of renal AKI
A
Acute tubular necrosis (85%)
Interstitial nephritis (10%)
Glomerular disease (5%)
10
Q
Causes of acute tubular necrosis
A
Drugs: aminoglycosides, cephalosporins, radiological contrast mediums, NSAIDs
Toxins: heavy metal poisoning, myoglobinuria, haemolytic uraemic syndrome
11
Q
Pathophysiology of interstitial nephritis
A
Mainly caused by drugs
Damage is not limited to tubular cells and bypasses the BM to cause damage to the interstitium
- mainly caused by abx, diuretics, PPI, allopurinol
12
Q
Management of interstitial nephritis
A
Withdrawal of the drugs and a short course of oral steroids
13
Q
Anatomy of the glomerulus
A
3 layers for substances to pass through
1. Fenestrated capillary epithelium
2. BM
3. Visceral layer: formed by interdigitating podocytes
These create a sieve that allows small, charged ions through
14
Q
Pathophysiology of glomerulonephritis
A
Antibody / T cell mediated immunological attack upon an antigen in the glomerulus which may be primary (always there) or secondary (acquired)
15
Q
Examinations / investigations in AKI
A
Obs : hypotension = pre renal / hypertension = CKD
OE: palpable bladder = bladder outlet obstruction
Urine dip and MCS
Bloods
VBG /ABG: to assess acid / base status
ECG: hyperkalaemia
Renal USS: to look for post renal causes
16
Q
Management of AKI
A
- Halt any damaging drugs eg ACEi / NSAIDs
- Treat pre renal causes with iv fluids
- Refer to urology to relieve obstruction
- Assess fluid status with volume replacement
17
Q
Indications for acute dialysis
A
Refractory hyperkalaemia
Refractory acidosis
Pulmonary oedema
Uraemic pericarditis / encephalopathy
18
Q
Causes of hyperkalaemia
A
AKI / CKD
Drugs: supplements, K sparing diuretics, ACEis, NSAIDs
Acidosis
Others: addisons / tumour lysis syndrome / burns
19
Q
How does hyperkalaemia present on ECG
A
Tall, peaked T waves
Widened QRS complex
Flattened P waves / prolonged PR interval
20
Q
What to do if there is >6.5mmol/L potassium or there are ECG changes
A
- Start continuous ECG monitoring
- 10ml of 10% calcium gluconate IV to stabilise myocardium (repeat at 5min intervals until a max of 3 doses)
- 50ml of 50% glucose with 10U ACTRAPID insulin into a large vein over 30mins to decrease K+ conc
- Consider 10mg salbutamol neb
- If pH <7.2 consider sodium bicarbonate IV if advised by renal reg
- Recheck K+ after 2 hours
- Calcium resonium can then be given orally / rectally - long term option
- Ensure underlying cause is being treated
21
Q
What is benign prostatic hyperplasia
A
Benign nodular / diffuse proliferation of glandular layers of the prostate, leading to enlargement of the inner transitional zone
Affects 70% of those >70
22
Q
BPH symptoms
A
Filling: urinary freq (nocturia), urinary urgency
Voiding: hesitancy, poor stream, post void dribbling, strangury, retention with overflow incontinence
Complications: haematuria, UTI, post renal aki
23
Q
BPB investigations
A
PR: enlarged prostate, typically the sulcus is still palpable
Bloods: FBC, U&E, PSA
Urinalysis
Bladder USS
Transrectal USS
24
Q
BPH complications
A
UTI
Overflow incontinence
Bladder calculi
Bladder diverticulae
Bilateral hydronephrosis and renal failure
25
Management of BPH
Acute:
- catheter to relieve obstruction (urethral or suprapubic)
Chronic:
- lifestyle: avoid alcohol + caffeine, relax when voiding, void twice in a row to help emptying, bladder retraining therapy
Alpha blockers: reduce SM tone
5a-reductase inhibitors: stop conversion of testosterone to dihydrotestosterone thus decreasing enlargement
26
Surgical management of BPH
Transurethral resection of the prostate
- 10% risk of impotence and 20% need repeat in 10years
- retrograde ejaculation almost universal
- bleeding
- hyponatraemia
Holmium laser prostatectomy
- endoscopic procedure used for very large prostates
- urinary incontinence may occur if too much gland is removed
27
Epidemiology of PCa
2nd most common malignancy in males
Present in 80% of males >80 but only 4% die from it
Slowly progressive malignancy
Mainly adenocarcinomas arising in peripheral prostate
28
PCa risk factors
Age
FH
Black ethnicity
Raised testosterone levels
29
PCa presentation
- often asymptomatic (found on PR)
- may present with filling, voiding or complication symptoms
- weight loss / bone pain suggest advanced metastatic disease
30
PR findings in prostate examinations
Hard ‘craggy’ prostate
31
PSA levels in PCa
>10mg/ml highly suggestive of tumour
Not a reliable screening method as can be affected by many factors such as cycling, UTI, recent intercourse and catheterisation
32
Gleason scoring for PCa
2 areas of biopsied tissue are graded out of 5 in terms of histological features of aggression to give a combined score out of 10
Gleason grade is vital for prognosis with scores of <6 being low risk and >8 being high risk
33
What is the D’amico risk stratification
Combines gleason score with clinical stage and PSA to give a more accurate prognostic score than gleason score
34
Management of T1/T2 prostate cancer
Patient choice between:
- active surveillance - regular PSA / DRE / biopsy
- curative surgery : radical prostatectomy
- curative radiotherapy / brachytherapy
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Management of T3/T4 prostate cancer
Choice between radiotherapy or surgery
36
Management of metastatic prostate cancer
Hormonal therapy is first line aiming to decrease the stimulatory effect of testosterone on PCa cell division
- androgen deprivation / blockade
Chemotherapy - used if relapsed on hormonal therapy
37
Prognosis of PCa
Has a 5 year survival rate of over 95% when diagnosed at stage 1-3
This falls to 49% of those with stage 4
38
Most common malignancy affecting the urinary system
Bladder cancer
39
What type of cell is mainly affected in bladder cancer
Transitional cell
40
Clinical features of bladder cancer
Painless frank haematuria
Lower urinary tract symptoms (frequency, urgency, dysuria)
Symptoms of bladder outlet obstruction (urinary retention / post renal AKI)
Fever
Weight loss
Malaise
41
Risk factors for bladder cancer
Smoking
Aromatic amines: rubber, plastic, dye
Chronic cystitis
Pelvic irradiation
42
Bladder cancer investigations
Urinalysis
Any painless haematuria should be assumed malignant (2WW referral for cystoscopy)
Any suspicious lesion will be biopsied or resected via a transurethral resection of bladder tumour
CT abdo
43
Treatment for bladder cancer T1 bladder carcinomas
Transurethral resection of bladder tumour performed at cystoscopy with intravesical chemotherapy
5 year survival 95%
44
Treatment of T2-T3 bladder carcinomas
Radical cystectomy is gold standard with pre-operative chemo
An ileal conduit is used to leave an urostomy
45
Treatment of T4 bladder carcinomas (invasion beyond bladder)
Palliative care
46
Risk factors of SCC of the bladder
Schistosomiasis
Bladder calculi
Chronic UTI
47
2 types of renal tumours
Vascular tumours that arise from the proximal tubular epithelium (90%)
TCC’s of the renal pelvis
48
Risk factors for renal cancer
Male
Smoking
HTN
Polycystic kidney disease
Chronic haemodialysis
49
Presentation of renal cancer
50% incidental findings
10% present with classic triad: haematuria, loin pain, abdo mass
- constitutional symptoms
- varicocele due to invasion of left renal vein
- polycythaemia
50
Renal cancer investigations
Urine cytology
USS to differentiate between solid and cystic mass
CT / MRI for tumour staging
Cannon ball lung metastases on CXR
Brain metastases also common
51
Treatment of renal cell carcinomas
Radical nephrectomy
Partial nephrectomy (if smaller than 5cm)
Post op immunotherapy
65% 5 year survival for renal disease treated surgically
52
What is a wilm’s tumour
Comprise 20% of childhood malignancies
Undifferentiated mesodermal tumour
Present generally at 3.5yrs with flank pain and abdo mass
Should not be biopsied
Tx:
- nephrectomy and pre-operative chemo
53
Aetiology of urinary tract calculi
Renal calculi form in the collecting ducts of the kidney and may then be deposited anywhere from the renal pelvis to the urethra
Commonly composed of calcium oxalate
15% lifetime risk
Peak age 20-40
M:F 3:1
54
Presentation of urinary tract calculi
Renal colic: excruciating loin to groin spasms with N&V, patient cannot lie still
Occurs if stone is impacted in the ureter
Dull loin pain - if the stone is in a major / minor calyx
UTI - secondary to the partial / complete obstruction
55
Risk factors for urinary tract calculi
Obesity
Dehydration / low fluid intake
FH / personal history of stone disease
Anatomical abnormalities
56
Investigations for suspected urinary tract calculi
Bloods
Urine dip
Urine MCS
Imaging : non contrast CT KUB
57
Acute management of urinary tract calculi
A-E assessment
75mg Diclofenac IM unless contraindicated
Avoid NSAID in the presence of AKI
IM metoclopramide if N&V
IV abx if signs of infection - infected obstructed kidney is surgical emergency
58
When should admission be indicated in urinary tract calculi
If there is still severe pain at 1hr
Risk of AKI
Signs of shock / infection
Uncertainty over diagnosis
59
Indications for active treatment in urinary tract calculi
Low chance of spontaneous passage
Persistent pain
Ongoing obstruction
Signs of infection
Renal insufficiency
60
What is extracorporeal shockwave lithotripsy (for urinary tract calculi)
Outpatient procedure that focuses shockwaves on the stone to break it up and it can then be passed spontaneously
61
What is uretoscopy
Various energy sources eg laser can be used to break up the stone
62
What is percutaneous nephrolithotomy
Used for renal calculi that do not respond to ESWL
63
Conservative treatment for urinary tract calculi
Tamsulosin (a blocker) or nifedipine (CCI) increase rate of spontaneous expulsion
Advise:
- many (80%) of stones will pass naturally
- maintain high fluid intake
- return if there is any increase in pain or infection
Try to pass urine through sieve to collect stone for analysis
64
Aetiology of UTI
E. coli is the most common organism involved
- proteus, staphylococcus, streptococcus, klebisella and pseudomonas
65
Clinical presentation of cystitis (lower UTI)
Frequency and nocturia
Dysuria
Urgency
Haematuria
Smelly urine
Suprapubic pain / tenderness
Strangury
66
Predisposing factors for cystitis
Female sex: due to short urethra
Pregnancy
Menopause
Obstruction / tract malformation
Catheter
Diabetes - reduced host defences
67
Cystitis investigations
Urine dip : nitrates and leukocytes indicate infection
Midstream urine MCS: confirm diagnosis if >10^5 pathogenic organisms / ml
68
Management of asymptomatic bacteruria
Treat only in pregnancy
69
Management of uncomplicated UTI
UTI in healthy non pregnant women
3 days of oral abx as per local guidelines
Drink plenty of fluids
70
Management of complicated UTI
Eg males, diabetes, structural anomalies, catheter
5-7 days abx treatment
If systemically unwell initiate the sepsis 6
71
Management of recurrent UTI
Consider renal tract imaging
Advise on high fluid intake, frequent voiding (inc after intercourse), avoidance of spermicidal jellies, avoidance of constipation
If this fails, prophylaxis with trimethoprim / nitrofurantoin at night
72
Clinical presentation of pyelonephritis (upper UTI)
High fever
Loin pain with tenderness
Rigors, vomiting and oliguria
Signs of sepsis
73
Investigations of pyelonephritis
As per lower UTI + bloods
- often markedly raised inflammatory markers
74
Management of pyelonephritis
Often systemically unwell and at risk of sepsis so hospital admission for IV abx therapy is generally required
75
What is a urethral stricture
A scar of the urethral epithelium which commonly extends into the underlying corpus spongiosum
Fibroblastic activity leads to a shortening of urethral length and narrowing of luminal size
76
Causes of urethral stricture
Blunt perineal trauma:
- straddle injury, pelvic fracture
Iatrogenic
- traumatic / long term catheterisation
Infective
- gonococcal
Balanitis xerotica obliterans
- rare, characterised by white atrophic plaques
77
Traumatic causes of urethral stricture
Straddle injury
Pelvic fracture
78
Iatrogenic causes of urethral stricture
Traumatic / long term catheterisation
79
Infective causes of urethral stricture
Gonococcal
80
What is Balanitis xerotica obliterans
A rare condition that causes urethral stricture characterised by white atrophic plaques leading to phimosis
81
Presentation of urethral stricture
Obstruction voiding symptoms that worsen gradually
- initial frequency / dysuria
- hesitancy / straining
- splayed stream
82
Severe presentation of urethral stricture
Urinary retention and post obstructive AKI
83
OE of urethral stricture
Areas of the penis consistent with periurethral scarring
No prostate abnormalities
84
Investigations for suspected urethral stricture
Uroflowmetry
Urethrogram: to determine stricture length, location, calibre and significance
Ureteroscopy
85
Management of urethral stricture
Catheterisation is necessary for those presenting in acute urinary retention
(Severe strictures and retention may require suprapubic catheterisation)
1st line is optical urethrotomy
Urethroplasty for those that recur (50%)
86
What is phimosis
Narrowing of the preputial orifice
Usually idiopathic
Can be congenital
Can be secondary to chronic Balanitis or forcible retraction of the foreskin
87
Presentation of phimosis
In children: ballooning of the foreskin and poor stream during urination
In adults: pain during intercourse and inability to retract foreskin
88
Management of phimosis
Topical corticosteroids
Advice to gently try to retract the foreskin nightly in warm baths
Circumcision
89
What is paraphimosis
A tight foreskin is pulled over the glans obstructing venous return, leading to a swollen painful glans. As it swells it becomes difficult to replace the foreskin.
This can occur following erection or urethral catheterisation
90
Treatment of paraphimosis
Emergency: local anaesthesia and then applying pressure to the glans
If this is unsuccessful incise a slit into foreskin dorsally
Circumcision can be offered to prevent recurrence
91
Luminal causes of bladder outlet obstruction
Bladder tumour
92
Mural causes of bladder outlet obstruction
Urethral stricture
Congenital abnormalities
Neuropathic bladder
93
Mural causes of bladder outlet obstruction
Urethral stricture
Congenital abnormalities
Neuropathic bladder
94
Extramural causes of bladder outlet obstruction
BPH
Prostatic carcinoma
Phimosis
Paraphimosis
95
What is priapism
Persistent erection of the corpora cavernosa of the penis
Corpora spongiosum remains flaccid
96
What is priapism
Persistent erection of the corpora cavernosum of the penis
Corpora spongiosum remains flaccid
97
Causes of priapism
Mainly idiopathic
Can be associated with C spine trauma, sickle cell disease and intracavernosal injections for impotence
98
Complications of priapism
If prolonged can cause ischaemia
Pain is a good indicator of this
99
Management of priapism
Emergency: local ice packs, IV hydration, high flow O2
Many then need needle aspiration of the corpus cavernosum +/- injection of alpha agonists
May need urgent urological review for surgical intervention
100
What is Peyronie’s disease
Upwards curvature of the penis when erect affecting 1-3% of all men
Can lead to sexual dysfunction
101
Cause of Peyronie’s disease
Fibrous scarring following trauma has been postulated
102
Management of Peyronie’s disease
Managing associated psychosocial issues eg depression
Surgical intervention may be indicated if there are issues with penetration
103
Causes of penis carcinoma
HPV 16/18
Smokers
Immunosuppression
104
Presentation of carcinoma of the penis
Persistent red patch on the penis progressing to an infiltrating ulcer
Never urethral involvement / symptoms
105
What is an epididymal cyst
Common condition due to cystic degeneration of epididymal structures
Associated with polycystic kidney disease and CF
Previously termed spermatocele
106
Presentation of epididymal cyst
Lump should be clear and transilluminate
Separate from the testes almost always at the upper pole
Contained fluid may be clear or contain sperm and be milky
Painful
107
Management of epididymal cyst
Can be excised if cause symptoms but drainage often leads to recurrence
108
What is a hydrocele
Collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis
Most common cause of scrotal enlargement
109
What is a primary hydrocele
Can be idiopathic or due to congenital defects in the processus vaginalis that allows communication between the tunica vaginalis and the peritoneal cavity
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What is a secondary hydrocele
Fluid collects due to underlying inflammation in the epididymis / testes or an underlying cancer
111
OE of hydrocele
Fluctuant swelling that transilluminates
112
Management of hydrocele
Most are not troublesome and reassurance of its benign nature is suitable treatment
If the swelling is causing problems excision of the hydrocele sac is possible
Aspiration often leads to recurrence
113
What is a varicocele
Varicosities of the pampiniform plexus most commonly on the left side
Presents in nearly 10% of men
Dragging sensation and dull ache
Associated with reduced spermatogenesis and subfertility
114
OE of varicocele
Feels like a bag of worms on palpation and they may only be palpable in the standing position
115
Why are varicoceles more common on the left side
Left testicular vein drains to the left renal vein whereas the right testicular vein drains to the IVC
Valvular incompetency at the junction of the left renal vein is what leads to varicocele
116
Management of varicocele
Reassurance of benign nature
Radiological embolisation of the left renal vein
Surgical ligation and division of the testicular veins
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What is testicular torsion
A surgical emergency occurring when the testicle twists upon its pedicel obstructing venous return
Without prompt relief the testicle will be unsalvageable
118
Epidemiology of testicular torsion
Predominantly adolescents 12-18
Usually history of mild trauma to the testicle or previous attacks of less severe pain due to partial torsion and spontaneous resolution
Usually due to a congenital abnormality eg testicular maldescent / bell clapper testes
119
Clinical presentation of testicular torsion
Sudden onset severe pain in the groin
Pain can sometimes be lower abdominal
Pain often associated with vomitting
120
OE of testicular torsion
Unilateral hot, swollen tender testis
Testis may be found lying high and transverse within the scrotum
Cremasteric reflex is absent
Stroking of the skin of the inner thigh normally causes the cremaster muscle to contract and pull the ipsilateral testicle towards the inguinal canal
121
Investigations for suspected testicular torsion
Doppler USS show lack of blood supply to testes in equivocal cases
Never delay surgical intervention if torsion is suspected
122
Differentials of testicular torsion
Epididymitis
Torsion of the testicular appendage
123
Management of testicular torsion
Manual distortion can be attempted under analgesia for temporary pain relief but urgent surgery still required
If testis is still viable:
- untwist and suture to the tunica vaginalis with fixation of the contralateral testicle also
If non viable:
- orchidectomy and fixation of the contralateral testis should occur
- salvage rate of 80% is achievable in patients operated on within 6 hours of initial torsion
124
What is torsion of the testicular appendage
Pathology and presentation similar to testicular torsion but it is an embryologically remnant that twists rather than the testicle itself
Less painful
No elevation of the testis
Classically causes a small blue nodule to become visible under the scrotum
Classically occurs at the start of puberty
125
What is epididymitis / epididymis - orchitis
Acute infection of the epididymis / epididymis and testicle
126
Aetiology of epididymitis
Infections most commonly arise due to ascending infection
- STI
- UTI
- haematogenous eg mumps / TB
127
Presentation of epididymitis
Painful swelling of the infected epididymis
- presence of testicular pain, swelling and tenderness suggests spread to the testes also
- history of discharge
- may be a reactive hydrocele
- rare systemically unwell
128
OE of epididymitis
Pain and tenderness on palpation of the epididymis
Positive phren’s test
Scrotal elevation relieves pain in epididymitis
129
Investigations for epididymitis
First catch urine MCS and STI screen
Scrotal USS to rule out other diagnoses
130
Management of epididymitis
Oral abx
NSAIDs
Scrotal elevation
Empiric abx are based on whether the man is high risk for STI and should always be reviewed once the STI / UTI screen is back
131
Risk factors for testicular cancer
Undescended / ectopic testes
Infertility
Hypospadia
Family / personal history
132
Pathophysiology of seminoma (testicular tumour))
Arise from the semineferous tubules
Classically seen in 30-40yr olds
Have a solid appearance macroscopically
Microscopically can range from well differentiated spermatocyte cells to undifferentiated round cells
133
Pathophysiology of non-seminomatous germ cell tumours (NSGCTs)
Including teratomas, yolk sac tumours and choriocarcinomas
Arise from totipotent germ cells classically seen in 20-30yr olds
Have a cystic appearance macroscopically and variable cell types microscopically
134
Clinical presentation of testicular cancer
Painless lump in the testes
Hydrocele
Haematospermia
Symptoms of metastases (abdo swelling or breathlessness) - first palpable node is likely to be supraclavicular
Can rarely present as gynaecomastia due to paraneoplastic hormone production
135
Testicular cancer investigations
Scrotal USS - can reveal a solid tumour in the presence of hydrocele
Tumour markers
- NSGCTs usually produce AFP, some bHCG
- seminomas - never produce AFP, 10% produce bHCG
CT CAP
136
Management of testicular cancer
Early surgical intervention
Retroperitoneal lymph node dissection
Adjunctive chemo +/- radiotherapy
Sperm banking due to the risks of infertility
137
Prognosis of testicular cancer
Node negative cases have nearly 100% 5 year survival
Overall 5year survival is >90%
138
Indications for urinary catheterisation
Acute urinary retention
A need for precise urine output monitoring eg AKI, sepsis, major surgery
For bladder irrigation
For patients requiring epidural anaesthesia
139
Contraindications of urinary catheterisation
Known abnormalities of the urethra
Recent urological surgery
140
Alternatives to urinary catheterisation
If the patient is able to void into bottles this can provide accurate urine output monitoring
For those requiring long term catheters, suprapubic catheterisation is preferred
141
Complications of urinary catheterisation
Introduction of infection
Traumatic insertion - haematuria, false passage creation, urethral strictures
Bladder stones / bladder malignancy
142
Red flags for bladder cancer
Patient >60
Unexplained, non visible haematuria
Dysuria or raised white cell count on blood test
143
First line analgesia for renal colic
IM Diclofenac
144
What is decompression haematuria
Occurs commonly after catheterisation for chronic urinary retention due to the rapid decrease in the pressure in the bladder
145
Management of overactive bladder
Antimuscarinic agent eg tolterodine or oxybutynin
146
What is a radical nephrectomy
Removal of the kidney, perinephric fat and local lymph nodes
Used for renal cell carcinoma invading renal capsule or >7cm
147
When is a partial nephrectomy done
RCC
Patients with a T1 tumour <7cm in size
148
What is the classic triad of renal cell carcinoma
History of haematuria
Flank pain
Palpable renal mass
149
Management of congenital hydrocele in a newborn baby
Reassurance and observation initially
If it doesn’t resolve then elective surgery in 1-2 years
150
What can acute urinary retention cause in older patients
Delirium
151
Side effects of alpha 1 adrenergic receptor antagonist eg tamsulosin
Dizziness + postural hypotension as it can cause systemic vasodilation
152
What is bladder voiding measured by
Urodynamic studies
153
What is the most common site affected in ischaemic colitis
Splenic flexure
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