Describe the physiological anatomy of the bladder.
▪ Body where the urine is retained
▪ Neck of the bladder is funnel-shaped extension passing into urogenital triangle and connecting with the urethra
▪ Detrusor muscle = smooth muscle cells linked together for the spread of an actio potenial
▪ Trigone on posterior wall - immediately above bladder neck - covers where the ureters enter
Describe the type of innervation that controls the internal sphincter, and its function.
▪ Autonomic innervation
▪ Prevents seminal regurgitation during ejaculation
Which of the following is the correct answer. The nervous supply of the bladder involves: A) Sympathetic Input only B) Parasympathetic Input only C) Somatic Input only D) All of the above
Answer: D
What is the role of sensory nerve fibers that are in the pelvic nerves which innervate the bladder.
Detect stretch signals from the bladder
A) Describe the sympathetic innervation of the bladder, including function.
B) Describe the parasympathetic innervation of the bladder, including function.
C) Describe the somatic innervation of the bladder, including function
A)
▪ Hypogastric Nerves (L1-L3)
▪ Function: causes the relaxation of the detrusor muscle allowing urinary retention
B)
▪ Pelvic nerves (s2-s4)
▪ Function: increased signals lead to the contraction of the detrusor muscle stimulating micturition
C)
▪ Pudendal nerve (S2-S4)
▪ Function: innervates external sphincter providing voluntary control over micturition
Through which plexus do the pelvic nerves connect with the spinal cord?
Sacral plexus (connects mainly with cord segments S2 and S3)
Briefly describe micturition.
▪ Emptying of the bladder when it becomes filled
▪ Filling occurs until the tension on its walls reaches a threshold
▪ Then micturition reflex occurs
What controls the peristaltic contractions of the calyces, pelvis and ureters?
Same control as the bladder (parasympathetic and sympathetic innervate the smooth muscle of the ureter)
How is reflux of urine from the bladder up the ureters ensured?
▪ Ureters course obliquely through the bladder wall for few centimeters
▪ Normal tone of the detrusor muscle when bladder contracts or is full leads to compression of the ureter preventing back flow
Name the condition whereby reflex does occur through the ureters due to anatomical abnormality.
Vesicoureteral Reflux (could damage the ureters, pelvis, and calyces)
Micturition reflex is a single compete cycle (an autonomic spinal cord reflex):
1) Progressive and rapid increase of pressure
a. Micturition reflex is “self-regenerative” - there is an initial contraction when the bladder is partially full-> activation of stretch receptors -> increase in sensory signals to sacral segment from bladder and posterior urethra -> more signals returning to the bladder through pelvic nerves by parasympathetic nerve fibers -> more contractions
2) A period of sustained pressure
a. More and more contractions continue to occur as they repeatedly activate the stretch receptors -> high degree of contraction of the bladder due to continuous contractions -> sustained pressure
3) Return of pressure to the basal one of the bladder
a. After few seconds to a minute the self-regenerative reflex begins to fatigue and cycle of the micturition reflex ceases permitting the bladder to reflex
b. If there is unsuccessful emptying, then nervous elements of the reflex are inhibited for >1 hour until more filling occurs
c. As the bladder becomes more and more full, the reflex occurs more frequently and therefore more frequent powerful contractions occur and that’s when you feel the urge to pee!
d. As contractions become stronger, signals from higher centers will inhibit the pudendal nerve which relaxes the external sphincter
e. Micturition will take place ONLY IF INHBITION SIGNALS TO THE PUDENDAL NERVE ARE STRONGER THAN THE VOLUNTARY STIMULATION SIGNALS
Describe how sufficiently powerful contractions lead to micturition.
▪ Sensory signals -> to the higher centers
▪ Facilitative centers inhibit hypogastric sympathetic nerve
▪ Hypogastric inhibition –> no relaxation of the detrusor and relaxation of internal sphincter
▪ Stimulation of pelvic parasympathetic nerves –> contraction of detrusor by acetylcholine acting on muscarinic receptors on the bladder
Inhibition of parasympathetic pudendal nerve (voluntary control) -> relaxation of external sphincte
Where are the higher control centre of micturition located?
Pons (there is a facilitative and inhibitory centre)
Describe how the higher centers inhibit micturition at partial filling volume of the bladder.
▪ Partial filling -> sensory signals also go up to the higher control centers due to the stretching of the receptors in the posterior urethra and bladder
▪ The control centers are mainly in the pons: there is an inhibitory center and a facilitative center
▪ Once the signal enters the spinal cord and travels up to the pons, it communicates with the cerebral cortex whether it is appropriate to empty the bladder or not
▪ If not, or the urge is not strong/the brain recognizes an empty bladder, then: signals from cerebral cortex will stimulate inhibitory center in the pons
▪ Inhibitory center sends signals which stimulate the hypogastric sympathetic nerve and parasympathetic pudendal nerves and inhibit pelvic parasympathetic nerve
▪ Hypogastric stimulation = detrusor relaxation + internal sphincter contraction (this is by norepinephrine)
▪ Inhibition of pelvic nerves = relaxation of detrusor muscle (acetylcholine on muscarinic (m3) receptor)
Stimulation of pudendal nerve = Contraction of the external sphincter (Acetyl choline on Nicotine receptors)
List abnormalities of micturition.
- Atonic bladder and incontinence due to destruction of sensory nerve fibres -> Overflow Incontinence
a. Despite working efferent fibres
b. Causes:
i. Most common: crush injury to the sacral segment of the spinal cord
ii. Disease that damages dorsal root fibres
1) Example: syphilis -> fibrosis in the dorsal root (called tabes dorsalis) -> tabetic bladder- Autonomic bladder caused by spinal cord damage above sacral region -> periodic but unannounced micturition
a. Micturition reflex disappears for days to weeks due to ‘spinal shock’ but then returns
b. Maybe able to stimulate micturition through stimulation of the skin of the genitialia by tickling or scratching - Uninhibited Neurogenic bladder caused by lack of inhibitory signals from brain -> any small amount of urine will stimulate micturition
a. Partial damage to brain or spinal cord which damages the inhibitory pathways
b. Lack of inhibitory signals but facilitative centre continues to produce signals
- Autonomic bladder caused by spinal cord damage above sacral region -> periodic but unannounced micturition
List Main causes of acute renal failure.
▪ Pre-renal = shock, major trauma (renal hypoperfusion -> loss of kidney function)
▪ Renal = glomerulonephritis, toxic (e.g. medications), malignant hypertension, vasculitis, analgesics
▪ Post-renal = obstruction
A) What are the three types of PKD?
B) List symptoms of PKD.
C) Prognosis?
D) What is the treatment of PKD?
A)
Autosomal Dominant PKD (children are born with it but symptoms do not appear until 30-60 years old)
Autosomal Recessive (Symptoms appear in childhood)
Non-inherited PKD
B) ▪ Abdominal Pain ▪ Hematuria ▪ Hypertension ▪ Kidney Stones
C)
Renal Failure
D)
▪ Medications and surgery for hypertension, pain, UTI;s and removing stones
▪ Dialysis
Kidney Transplant
List kidney functions.
- Maintains electrolyte balance
- Regulates blood pressure
- Produced erythropoietin which is required for RBC production
- Excretion of waste
What is the pathology of nephrotic syndrome?
▪ Damage to the podocytes (epithelial cells) which leads to the loss of protein
Common Causes:
▪ Primary causes = kidney disease (minimal change nephropathy, focal segmental glomerulosclerosis)
▪ Secondary causes = diabetes, lupus, amyloidosis
Describe Nephritic Syndrome.
Symptom/Signs:
▪ Haematuria
▪ Proteinuria (usually less than nephrotic)
▪ Pain
▪ Oliguria (due to damage to glomerulus so less filtration)
▪ Hypertension (reduced filtration -> increase intravascular plasma volume)
▪ Oedema
Pathology:
Antigen-antibody complexes activate complement (these complexes either form at the glomeruli or else where and get to the glomeruli) -> recruitment of WBC -> inflammation and damage of endothelial cells (capillary cells) -> White blood cells and red blood cells get through -> protein also gets through
Common causes:
SLE
Goodpasture Syndrome (Anti-GBM ANTIBODY disease)
A) Describe the clinical presentations of kidney stones.
B) Name some complications of kidney stones.
C) What are the different types of calculi (stones)
D) List risk factors of urinary calculi.
A) ▪ Renal Colic ▪ Hematuria ▪ Pain on urination ▪ Cloudy or foul smelling urine ▪ Frequent urination ▪ Pyelonephritis symptoms (secondary infection -> fever, chills, tachycardia)
B)
▪ Pyelonephritis
▪ Obstructive uropathy –> Hydronephrosis –> post-renal renal failure
C) ▪ Calcium stones (most common)
▪ Uric Acid stones
▪ Cystine stone - due to hereditary condition where your kidneys filter too much cystine -> cystinuria
▪ Infection stone - struvite stones
D) ▪ Hypercalcemia § Sarcoidosis § Renal tubular necrosis § Hyperparathyroidism ▪ Gout ▪ Obstruction ▪ Genetic ▪ Dehydration
A) Name the most common malignant tumor in children
B) Describe features of this condition.
A) Name the most common malignant tumor in children
Wilms’ Tumour
B) Describe features of this condition.
WT1 tumor suppressor gene
Affects children usually under 3
The younger the better the prognosis
Surgery, radio, chemo leads to 90% survival
List the most common carcinomas for the follow: prostate, bladder, renal.
Prostate - adenocarcinoma
Bladder - urothelial (transitional cell) carcinoma
Renal - 4/5 are clear cell carcinoma (ccRCC)
Renal Cell Carcinoma - Clear Cell
A) Presentations?
B) What organ is particularly at risk with the metastasis of renal carcinoma?
C) List risk factors for RCC.
Presentations: ▪ Haematuria ▪ Pain ▪ Mass/Swelling ▪ Paraneoplastic syndrome ○ Pyrexia (if you do fbc and no wbc then think carcinoma) ○ Hormonal disturbances (Increased erythropoietin -> increased RBC -> polycythemia which hints at renal neoplasm) ▪ Metastasis
What organ is particularly at risk with the metastasis of renal carcinoma?
▪ Heart (grows through renal vein -> IVC -> heart)
▪ Lungs same way (‘cannonball lesions’)
List risk factors for RCC.
▪ Smoking
▪ Obesity
▪ Chronic Cystic disease
▪ Men>women
A) What is the most common type of bladder cancer?
B) List the presentations of bladder cancer.
C) What are the risk factors of bladder cancer?
D) Describe other features of bladder cancer.
A) What is the most common type of bladder cancer?
▪ Papillary carcinoma (others= flat invasive and flat non-invasive)
B) List the presentations of bladder cancer.
▪ Hematuria
▪ Dysuria
▪ Obstruction
C) What are the risk factors of bladder cancer?
▪ Smoking
▪ Exposure to carcinogen - industrial –> aniline dyes (used for water colors and fabrics)
D) Describe other features of bladder cancer.
▪ Bladder cancer comes in a spectrum of malignancy from superficial, carcinoma in situ to deeply invasive
▪ Tendency to occur (this is because the carcinogens that induce it tend to be concentrated in the urine which mean the whole epithelial of the bladder is exposed)
▪ Requires monitoring (cystoscopy - 6 monthly or annual basis)
How does AKI differ from CKD in terms of symptoms/presentations?
▪ CKD = anemia due to loss of synthetic function
▪ Small kidneys in CKD but maybe enlarged in AKI
▪ Other presentations are the same
▪ Hyperkaliemia ▪ High creatinine ▪ May be oliguria ▪ Hypertension ▪ (Lipids in nephrotic syndrome)
Name the three common disorders of the prostate.
▪ Benign prostatic hyperplasia
▪ Carcinoma
▪ Prostatitis
A) Describe the signs and symptoms of BPH.
B) Name the most common type of BPH.
C) Describe the features of Benign nodular hyperplasia.
A) ▪ Frequency and urgency ▪ Nocturia ▪ Difficulty starting urination ▪ Weak urine stream ▪ Stream that stops and starts ▪ Dribbling at the end of urination Inability to completely empty the bladder
B)
C)
Name the difference in presentations between BPH and prostate carcinoma.
▪ BPH may present with urinary symptoms as the growth starts from the middle of the prostate/center
Carcinoma will have no urinary symptoms as the grow is on the side/outside of the prostate
A) Where is the most likely metastasis pf prostatic cancer.
B) Describe the presentations of prostatic carcinoma.
C) Describe the diagnoses of prostatic carcinoma
D) Describe the treatment of prostatic carcinoma.
A) Bone
B) ▪ Urinary symptoms ▪ Incidental finding on rectal examination ▪ Bone metastasis Lymph node metastasis
C)
▪ Imaging - USS, X-RAY, ISOTOPE BONE SCAN
▪ Cystoscopy - unlikely ot be useful
Hematological - if bone marrow involvement
D) ▪ Estrogenic ▪ GnRH analogues ▪ Orchidectomy ▪ Radiotherapy Radical prostatectomy
List the three sociological theories of chronic illness experience.
▪ Biographical work catalyzed by chronic illness (Biographical disruption - Bury 1982)
• Illness is always disruptive and when it comes clear that it is not self-limiting or cured leads to changes in a person’s perception of themselves and of their position in society
• Control over trajectory of life is lost - rethinking of one’s mortality and existential sense
• Catalyzes a process of adaptation:
○ Coping - cognitive processes of learning how to tolerate or put up with effects of illness
○ Strategies - actions people take in the face of illness
○ Style - the way people respond to and present important features of their illness
▪ Loss of self (Charmaz 1983)
• Chronic illness has profound effects on a person’s sense of self-worth
• Individuals separating off the person they have become from how they were
▪ Biographical/narrative reconstruction (William 1984)
• Rebuilding of one’s identity incorporating the chronic illness
• View of one’s self becomes almost exclusively linked to that of the disease
A) What is UTI?
B) What is most common causative agent?
C) List symptoms.
D) Describe diagnosis.
A)
Urinary symptoms + bacteriuria
B)
Usually E.Coli (Gram -ve)
C) ▪ Can be asymptomatic ▪ Frequency ▪ Dysuria ▪ Haematuria ▪ Foul-smelling +/- cloudy urine ▪ Urgency ▪ Urinary incontinence ▪ Pyrexia ▪ Suprapubic pain
D) History: previous UTI, SH, antibiotic use, any history of renal tract abnormality, diabetes immunosuppressent agents, FH Physical Exam of kidney and bladder Dipstick Urine microscopy USS to rule out structural abnormalities
TX:
- Analgesics
- Fluids
- Trimethoprim if treating empirically unless you have confirmation of the pathogen/sensitivity
Complications: ▪ Pyelonephritis ▪ Perinephric or intrarenal abscess ▪ Hydronephrosis ▪ Aki Sepsis
A) What are the causes of Epidiymo-orchitis?
B) Describe how Epididymo-orchitis may present.
C) What are the investigations?
D) Describe Tx.
A) • Infection
○ Ascending STI (Chlamydia, gonorrhoea, mycoplasma genitalium)
○ Men who have sex with men (coliform bacteria from anal sex)
○ UTI (Coliforms like E.Coli)
B) ▪ Unilateral scrotal pain and swelling, proteus)
▪ Pyrexia
▪ Urethritis if sexuall acquired
▪ Symptoms of UTI
C)
Gram stain of a urethral smear (even if there is no urethral symptoms)
NAAT swap + First pass urine
Bloods (CRP)
Sexual risk - other sexual health screening based on sexual history
Testing for other causes - for example if mumps
USS if acute onset - MUST RULE OUT TESTICULAR TORISION
Diagnosis based on history and investigations
D) ST organisms - doxycycline twice a day for 14 days + ceftriaxone 500 mg IM as once only
If gonorrhoea - azithromycin 1 gram - you should add this
If you think it maybe enteric organism you should consider ofloxacin tablets
Anti biotice usually are effective within three days in terms of seeing improvement (till then,
A) What is pyelonephritis?
B) What are the risk factors?
C) Sx?
D) Investigations?
E? Describe treatment.
A) Infective inflammatory disease of the renal parenchymal (calyces and pelvis)
▪ Gram Negative Bacteria - E.Coli (60-80% of cases), klebsiella (20% of cases) proteus marabelsu (15%). Others: pseudomonas
B) ▪ 15-29 year old females ▪ Urinary structural abnormalities ▪ Recent instrumentation of the urethra (ay recent surgeyr?) ▪ Pregnancy ▪ Immunocompromised (e.g HIV, Diabetes)
C) ▪ Lower Urinary Tract Symptoms: Frequency, Urgency, Hesitancy, Dysuria ▪ Flank Pain ▪ Fever ▪ Rigor ▪ Nausea ▪ Vomiting Might be some tenderness in the flank area and suprapubic area
D)
▪ Mid stream urine or catheter specimen if applicable before starting antibiotics
▪ Urine dipstick might be helpful
FBC - WBC and CRP
E)
▪ Empirical Antibiotic treatment before cultures and sensitivities are back ○ Co-trimoxazole for men and non-pregnant women ○ Co-amoxiclav for renal impaired patients ○ Cefalexin for pregnant women ▪ Consider analgesics
A) How does urethritis present?
B) Diagnosis:
C) How do you differentiate between gonococcal and NGU urethritis?
D) Treatment?
A)
Urethral discharge
Dysuria
Penile discomfort
B)
Microscopy - Cotton tip swap and we place it about 1 cm into the urethra and rub it against the glass slide
If gram -ve = probably gonorrhoea
If not gonorrhoea = non-gonococcal urethritis (NGU)
C) ▪ Gonorrhoea = gram -ve intracellular diplococci
NGU = >4 PMNL (polymorphnuclear leukocytes = granulocytes) field of urethral smear
D)
▪ If gonorrhoea = ceftriaxone IM 1g
▪ NGU = Doxycycline 100mg twice a day for 7 days
Tell patient to abstain from sexual contact
Describe the difference between acute and chronic prostatitis.
Acute Presentations
▪ Pain around the genitals (penis, testicles, anus, lower abdomen, lower back and passing poo is painful)
▪ Urinary symptoms: dysuria, frequency, nocturia, hesitancy, problems stop-start peeing, urgency, haematuria in some cases
▪ Acute Urinary Retention (requires urgent medical attention)
▪ Malaise
▪ Small amount of thick fluid discharge
Chronic presentations:
▪ Enlarged tender prostate on rectal examination
Sexual problems - ED, pain when ejaculating or pelvic pain after sex.
Prostatitis:
A) Diagnosis
B) Management.
Diagnosis:
▪ Exclude epididymo-orchitis by palpating the testicles
▪ MSU before antibiotics are given - Isolation of causative organism from urinary sample
Management:
Give antibiotics after MSU
Antibiotics (taking into account any resistance) = ciprofloxacin 500g twice daily for 14 days (if unsuitable use trimethoprim)
At what % is there desire to void the bladder?
75%
Voluntary control to maintain after that
What is the type of receptors at the internal sphincter?
Alpha receptor (sympathetic)
What happens during voiding phase of micturition?
- Voluntary and reflex relaxation of the pelvic floor (parasympathetic)
- Reflex detrusor contraction (parasympathetic)
- Intravesical pressure -> urethral pressure
Simply define the following types of incontinence:
1) URGE UI
2) OVERFLOW UI
3) Stress UI
1) Detrusor dysfunction
2) Bladder over distention with chronic retention
3) Sphincter dysfunction - involuntary urinary leakage on effort, exertion, sneezing, laughing, or coughing (The intra abdominal pressure is higher than the urethral closure pressure) - sphincter deficiency (internal or external) or pelvic floor weakness
Stress UI in women
A) List RFs of stress UI
B) List Sx/Hx.
C) Investigations?
D) Management?
A)
- Child birth(parity) - vaginal delivery and forceps
- Ageing
- Oestrogen withdrawal
- Pelvic surgery
- Neurological (MS)
- Increase in abdominal pressure due to obesity or chronic cough (e.g. smokers)
B)
- Involuntary leaking when laughing, coughing, sneezing, exertion
- Wearing pads
- Parity
C)
- Pelvic exam
- Stress test
- Pad test
- Bladder diary
- ICIQ-UI
- Urine dip +/- MSU
- Urodynamics (if surgical management is considered)
- Cystoscopy if indicated
D)
- Conservative = pelvic muscle training (30% of women with mild symptoms improve)
- Life style = weightloss, smoking, modigy fluid intake
- Medication - duloxetine (Second Line)
- Surgery (urethral bulking agent, artificial sphincter)
(Exercise -> Medication -> Surgery)
Stress UI in men
A) List RFs of stress UI
B) Investigations?
D) Management?
A) Main cause = post-prostatectomy sphincter incompetence (removal, damage to innervation, or damage to external sphincter)
- Age
- Radiotherapy
B)
- Stress test
- Pad test
- Questionnaire - ICIQ-MLUTS
- Post void residual
- Videourodynamics
- Cystoscopy
C) Conservative - Pelvic floor training (Not a cure - but speeds recovery) - Pads - Penile sheath
Lifestyle
Surgical
- Slings
- Artifical Sphincter
A) Describe cause and presentation of Urge incontinence.
B) Describe Exams and investigations
C) Describe treatment.
A)
- Part of symptoms syndrome of overactive bladder
- History = Frequency, urgency, urge incontinence, nocturia
- Due to overactive detrusor
- Urgency (you have an urge to urinate then you do)
- Frequency
- Nocturia (a lot of the time at night)
- Age is a risk factor (>40), but can be caused by infections or neurological
B)
- Abdo and pelvic exam
- DRE if relevant
- Neuro Exam
- Questionnaire (ICIQ-OAB)
- Pad
- USS
- Urodynamics
C)
- Conservative (Bladder training, pelvic floor exercises, modification of fluid intake)
- Medical:
- Anti-cholinergics (Tolterodine, solifenacin)
- Mirabegron - B3 adrenoreceptor agonist
- Topical oestrogen
- Intravesical botulinum toxin
- Surgical:
- Sacral nerve stimulation
- Clam ileocystoplasty
- Urinary Diversion
What do you do in mixed incontinance?
Treat predominant symptoms first
Overflow Incontinence:
A) Causes?
B) History/symptoms
C) Investigation?
D) Management?
A)
- Detrusor failure
- Neuro
- Bladder overflow obstruction
- Combination
B)
- Bedwetting in older patients
- Frequency
- Recurrent UTI’s
- Post void residual volume >800ml
C) U and E, USS
D) Treat cause
What are anatomical causes of incontinence?
- Vesico-vaginal fistula
- Urethral diverticulum
- Ectopic Ureter
A) In what age is complete ED most common and why?
A) >80yo, dye to increase in atherosclerosis in penile arteries and ischaemia and fibrosis
A) What are the RF’s of ED.
B) What are the investigations?
C) Describe management of ED.
D) What is the management of ED
A)
- DM
- CVD: HTN, High lipids, PVD
- Endocrine or neurological
- Surgery/trauma/radiotherapy
- Psychological (stress, anxiety, depression, pt expectations)
- Drugs (Prescribed, OTC, recreational, ED treatments tried)
- Social - smoking, alcohol
B)
- Bloods (fasting glucose, early morning total testosterone (8-11am), fasting lipids
- BP
- IIEF (Questionnaire to score the severity)
C)
- Psychosexual (counselling, sex ed, partner comm skills, cbt)
- Drug (PDE5 inhibitors (e.g. sildenafil = viagra), testosterone replacement)
- Intraurethral therapy
- Intravascular injection
- Vacuum device
- Penile implant
List the most common acute urinary presentations.
- Benign Prostatic Hyperplasia - Urinary Retention
- UTI’s
- Renal or Ureteric Calculi - hydronephrosis
- Testicular swelling + pain - torsion
A) What does pain and haematuria indicate?
B) Describe management.
A)
- Renal or Urteric Calculi
- Loin to groin pain
B)
- Extracorporeal shock wave lithotripsy
- Percutaneous Nephrolithotomy
- Ureterscopy
A) What does Nocturia, increased frequency, hesitation and poor stream indicate?
B) What is the treatment?
A) - BPH
B)
Alpha-1 Receptor antagonits = alfuosin, doxazosin/ Tamsulosin/
5 ALPHA-REDUCTASE INHIBITOR = finasteride
TURP (Trans urethral Resection of prostate)
What should you be thinking if someone presents with scrotal pain and swelling?
Rule out testicular torsion!
- Manage with surgical exploration
What should you rule out if someone comes in with left testicular varicocele?
Rule out renal tumour on the left! ad the left testicular vessels/vein drains into the left renal vein (only left side tumour would cause this)
(Manage with embolisation and stick a coil)
What is it called if the foreskin is over the head of the penis and too tight and doesnt retract?
- Phimosis (Manage with circumcision)
Paraphimosis is if it retracted and tight - manage with dorsal slit
Describe the investigations for pain and haematuria presentation.
- Urine Dipstick
- Ultrasound renal
- CT KUB
What does painless haematuria indicate?
50/60% RENAL CELL CARCINOMA
A) Describe the aetiology of urinary tract obstruction.
A)
- Children (Congenital - urethral valves in boys where they have extra flaps of tissue, or megaureter where there is defective peristalsis)
- Females (pelvic disease, pregnancy, stones)
- Males (stones and prostate)
A) What is retroperitoneal fibrosis?
B) Describe the presentations of Retroperitoneal fibrosis.
C) How do you manage?
A) Inflammation/fibrosis of ureters and aorta encircles ureters leading to extraluminal ureteric obstruction that can be unilateral or bilateral)
- It is mostly idiopathic
- Systemic Autoimmune disease with HLA association and IgG4 implicated)
B)
Weight loss, malaise, back pain, and urinary symptoms
(Do Bloods for CKD,CRP, AND ESR plus CT which shows medial deviation of the ureters.)
C)
1- Relieve obstruction
2- Post-obstructive diuresis
3- Treat underlying cause (use steroids here)
A) Describe the history of Urinary Tract Obstruction.
B) What does exam reveal?
C) Describe investigations
A)
- Pain - loin pain which is usually worse when passing water
- Urine output - anuria, polyuria with partial obstruction
- LUTS
- Complications with renal impairment/infection
- Acute urinary retention with severe pain
B) CKD signs (e.g. oedema + hypertension), pain and distress, enlarged kidney, loin tenderness
C)
- Urine dip (BLOOD, LEUC,NIT,PROTEIN)
- MSU (TO LOOK FOR INFECTION)
- Bloods (U+E/eGFR (aki and ckd), PSA, CRP/ESR
- USS
- Plain AXR
- Cross sectiona imaging
- IVU
- Cystoscopy
Describe the management of URINARY TRACT OBSTRUCTION.
1- Relieve the obstruction
- Urinary catheter or suprapubic (if there is significant obstruction which doesn’t allow normal flow)
- Percutaneous Nephrostomy (small tube into the renal pelvis to drain it)
- Stenting (cystoscopy then insert it)
2- Post-obstructive diuresis (increase/excessive urine production following the relief of the obstruction - so monitor the UO after relieving procedure but this is usually self-limiting)
3- Treat underlying cause
List some causes or renal stones.
- Dehydration
- Hypercalcaemia (Due to primary hyperparathyroidism, or high intake)
- Hyperuricaemia - gout (excess uric acid in blood)
- Primary renal disease (PKD)
- Drugs (Loop diuretics which increase calcium, thiazides which increase uric acid, and indinavir which is HIV antiviral therapy which is a protease inhibitor)
A) Describe presentation of kidney stones.
B) Investigations/exam.
C) Management.
A)
- Restless/Agitated
- Pallor
- Diaphoretic (sweating heavily)
- Pain
- Haematuria
B)
- Urine dip (Blood + Protein)
- MSU (Infection)
- Blood (eGFR, U + E, Calcium/urate/biocarbonate)
- Urine test for calcium /urate etc
- Analysis of stone
- Imaging USS, PLAIN AXR, IVU, CTKUB
D)
- Treat renal colic with Diclofenac (NSAID), opiate analgesia, and maintain UO
- Stones <0.5cm will pass spontaneously
- Stones >1cm will often need intervention (ESWL, Ureterscopy with YAG laser, Percutaneous nephrolithotomy)
- General advice to keep fluid intake high and UO 2.5L daily, reduce salt intake, and have moderate protein intake
- Hypercalcuria - treat with thiazides
- Infective stones - treat with antibiotics
- Uric acid - allopurinol
State the two categories of urinary tract symptoms.
Voiding: Related to passing urine
Hesitancy, straining, intermittency, weak stream
Storage: Related to storing urine, nocturia
Frequency, urgency, incontinence, terminal dribbling, nocturia
What is cetirizine used for?
Hay fever - relief of allergy
Why may a patient with heart failure get Nocturia?
HF -> Reduced blood flow to kidneys -> reduced filtration -> loading -> at night there is better renal haemodynamic due to the laying down position -> increased filtration at night
Which drugs make symptoms worse?
- Anti depressants
- Antihistamines
- Bronchodilators
Dysuria + microscopic haematuria
likely UTI
What are the three drugs that are used for lower tract symptoms.
▪ Alpha-1 receptor antagonist
○ Alfuzosin, doxazosin
○ First line treatment for LUTS
○ MOA: decrease smooth muscle tone in prostate and bladder
○ Efficacy: improve symptoms in around 70% of men
○ SE: dizziness, postural hypotension, dry mouth
○ Review for side effects and evidence of improvement at 4-6 weeks
▪ 5 alpha-reductase inhibitors
○ Finasteride
○ MOA: blocks conversion of testosterone to dihydrotestosterone which is known to induce BPH –> reduces prostate volume so may slow disease progression yet this takes time and improvement may not be seen for 6 months
▪ Anticholinergic agents
○ Solifenacin
○ For patients with overactive bladder
○ Caution in patients with dementia and consider over all anticholinergic burden in the elderly
○ Avoid If untreated closed angle glaucoma
○ SE: dry mouth, constipation, blurred vision
○ Review at 4-6 weeks
Review every 6-12 months
Name two drugs used for treatment of Benign Prostatic Hyperplasia.
▪ Tamsulosin Hydrochloride (Alpha-adrenergic blockers)
Finasteride
Explain why smoking, alcohol may lead to erectile dysfunction.
▪ Reduce nitric oxide and cause autonomic neuropathy
What drugs can cause ED?
Chemical - drugs (digoxine, beta-blockers, diuretics, anitdepressants, oestrogens, finasteride, narcotics
Describe the relation between cycling and ED.
▪ Some evidence to suggest that long distance cylcing (for more than 3 hours a week) can produce ED
▪ Due to nerve damage arising from contact with the saddle
▪ Reversible - no cycling period to allow nerve repair
Give the class of drugs that you would prescribe for ED regardless of the suspected cause of ED. And give an example of this class of drugs.
▪ PDE-5 inhibitor
▪ Sildenafil (viagra)
What should you tell a patient about PSA.
- Higher PSA linked to higher likelihood of cancer
- But it is produced in other conditions such as BPH, UTI, Recent ejaculation, or following digital rectal examination
- PSA which is high still requires biopsy
- many people have prostate cancers which will never become fatal (occurs in 40% os positive screens)
- Only 1 in 800 men avoid death because of this test
Describe the influence of family history on prostate cancer.
▪ Age important if male relative affected before 60
▪ Age no as important if relative affected when very elderly
▪ First-degree relatives brother/father most important in family history
○ 1 First-degree male relative affected = x2.5 risk
○ 2 First-degree males = 8x risk
BRCA 2 and BRCA 1 are relevant if discussing cancer in the family - ask about ovarian and breast cancer
List the options for prostate cancer treatment
▪ Active Surveillance
▪ WATCHFUL WAITING
▪ Surgery (Radical Prostatectomy - key hole surgery, requires three nights in hospital and 2-3 weeks catherization - 50% will become impotent due to nerve damage - need pelvic exercises after as some loss of control may be present)
Radical Radiotherapy with androgen deprivation - causes skin soreness and bowel and bladder irritation, potential ED
What is a Fiducial Marker?
▪ Small gold seed placed by transrectal ultrasound probe before treatment commences to help focus radiotherapy treatment accurately
