Lecture 9: Presentations of Diseases of the Kidneys and Urinary Tract Flashcards by Emma Thomson

which structures compose the upper urinary tract?

Kidneys:
- parenchyma
- pelvi-calyceal system

Ureters:
- pelvi-ureteric junction
- ureter
- vesico-ureteric junction

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which structures compose the lower urinary tract?

bladder
IUS
prostate (men)
EUS
urethra
urinary meatus
foreskin (men)

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aetiology of renal diseases

infection: pyelonephritis
inflammation: glomerulonephritis, tubulointerstitial nephritis
iatrogenic: nephrotoxicity, PCNL
neoplasia: renal tumours, collecting system tumours
trauma: blunt trauma
vascular: atherosclerosis, hypertension, diabetes
hereditary: polycystic kidney disease, nephrotic syndrome

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clinical presentation of renal disease

pain
pyrexia
haematuria
proteinuria
pyuria (pus in urine)
mass on palpation
renal failure

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what is considered proteinuria?

urinary protein excretion > 150mg/day

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in clinical practise, how many types of haematuria are there?

three

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what is considered microscopic haematuria?

> /= 3 red blood cells per high power field

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what is considered oliguria?

urine output < 0.5ml/kg/hr

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what is considered anuria? absolute and relative

absolute anuria: no urine output
relative anuria: < 100ml/24 hours

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what is considered polyuria?

urine output > 3L/24 hours

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what is considered nocturia?

waking up at night >/= 1 occasion to micturate

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what is considered nocturnal polyuria?

nocturnal urine output >1/3 total urine output in 24 hours

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which factors should be excluded when investigating polyuria and polydipsia?

chronic renal failure
hypokalaemia
hyperglycaemia
hypercalcaemia
thyrotoxicosis
diuretics
diet

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presentation of chronic renal failure

asymptomatic (found on blood and urine testing)
tiredness
anaemia
oedema
high blood pressure
bone pain due to renal bone disease

in advanced renal failure:
- pruritus
- nausea/vomiting
- dyspnoea
- pericarditis
- neuropathy
- coma (untreated)

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presentation of ureteric disease

pain (e.g. renal colic)
pyrexia
haematuria
palpable mass (i.e. hydronephrosis)
renal failure (only if bilateral obstruction or single functioning kidney)

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presentation of bladder diseases

pain (suprapubic)
pyrexia
haematuria
recurrent UTIs
chronic urinary retention
urinary leak from vagina (i.e. vesico-vaginal fistula)
pneumaturia (i.e. colo-vesical fistula)

Lower urinary tract symptoms:
- storage i.e. frequency, nocturia, urgency, urge incontinence
- voiding i.e. poor flow, intermittency, terminal dribbling - due to underactive bladder
- incontinence i.e. stress, urge, mixed, overflow, neurogenic, dribbling etc.

what is the risk of bladder cancer in patients with macroscopic haematuria?

25-30%

what is the risk of renal cancer in a patient who presents with macroscopic haematuria?

0.5-1%

list the possible causes of lower urinary tract symptoms (LUCTS) i.e. voiding LUTS, storage LUTS, incontinence polyuria etc.

bladder pathology: OAB, UTI, interstitial cystitis, bladder cancer
bladder outflow obstruction
pelvic floor dysfunction
neurological causes: supra-pontine lesions (e.g. stroke, alzheimer;s, parkinson’s), infra-pontine supra-sacral lesions (e.g. spinal cord injury, disc prolapse, spina bifida), infra-sacral lesions (e.g. MS, diabetes, cauda equina compression, surgery to tetroperitoneum)
systemic disorders: chronic renal failure, cardiac failure, diabetes mellitus, diabetes insipidus)

list the areas of the CNS involved in controlling micturition

1) cortical centre (bladder sensation and conscious inhibition of micturition)
2) pons (micturition centre)
3) sacral segments (S2-S4) (micturition reflex) causing:
- relaxation of IUS
- relaxation of EUS
- contraction of detrusor muscle

presentation of bladder outflow tract diseases

pain (suprapubic or perineal)
pyrexia
haematuria
LUTS
recurrent UTIs
acute urinary retention
chronic urinary retention

define acute urinary retention

painful inability to void urine with palpable and percussible bladder

aetiology of acute urinary retention

main risk factor: benign prostatic obstruction (BPO)
UTI
urethral stricute
alcohol excess
post-op causes
acute surgical or medical problems

what is the immediate treatment for acute urinary retention?

catheterisation

define chronic urinary retention

- painless, palpable and percussible bladder after voiding - patiebts often able to void but with residuals ranging from 400ml to >2 litres depending on stage of condition.

what is the main aetiological factor in chronic urinary retention?

detrusor muscle underactivity which can be primary (i.e. primary bladder failure) or secondary (i.e. due to longstanding bladder outflow obstruction, such as BPO or urethral stricture)

chronic urinary retention presentation

- LUTS - complication e.g. UTI, bladder stones, overflow incontinence, post-renal or obstructive renal failure - asymptomatic, incidental finding

in high-pressure chronic urinary retention, which two types of diuresis may occur?

- physiological (usually < 200ml/hr) - pathological (usually > 200ml/hr)

treatment of chronic urinary retention

- immediate: catheterisation - subsequent: long-term urethral or suprapubic catheter, CISC or TURP if due to benign prostatic obstruction (BPO)

what does a diagnosis of a UTI require?

- microbiological evidence: bacteral count of 10^4 cfu/ml from MSSU specimen with no more than two species of micro-organisms. - symptoms/signs, at least one of the following: fever > 38, loin/flank pain or tenderness, suprapubic pain or tenderness, urinary frequency, urinary urgency, dysuria

what are the two types of UTIs?

- uncomplicated UTIs (young sexually active females only with clear relation to sexual activity) - complicated UTIs (everyone else, always need to be investigates)

complications of UTIs

- infective: sepsis (esp. pyelonephritis), perinephric abscess - renal failure (scarring) - bladder malignancy (squamous cell carcinoma) - acute urinary retention - frank haematuria - bladder or renal stones

UTI investigations

- MSSU/CSU - lower tract: flow studies, residual bladder scan, cytoscopy - upper tract: USS kidneys, IVU/CT-KUB, MAG-3 renogram, DMSA scan

UTI treatment

- appropriate antibiotic therapy (type? duration? route?) - treat complications and cause

list emergencies related to urinary tract diseases

- acute renal failure - sepsis - renal colic - severe haematuria causing haemorrhagic shock - metastatic disease - acute urinary retention - chronic high-pressure urinary retention - iatrogenic injury/trauma to upper or lower urinaru tract, penis and testis - testicular torsion - paraphimosis - priapism

list the organisms commonly associated with UTIs

- E.coli - Klebsiella species - proteus species - pseudomonas aeruginosa