What are urinary tract disease classed as?
Upper or lower
Upper urinary tract diseases include diseases of what?
Kidneys - parenchyma, pelvic-calyceal system
Ureters - pelvis-ureteric junction, ureter, vesico-ureteric junction
Lower urinary tract diseases include diseases of what?
Bladder
Bladder outflow tract - bladder neck, prostate, external urethral sphincter/pelvic floor, urethra, urethral meatus, foreskin
What are the dividing causes listed in the surgical sieve?
Infection Inflammation Iatrogenic Neoplasia Trauma Degenerative Congenital Genetic/hereditary Vascular Endocrine Failure Idiopathic
What is oliguria?
Urine output < 0.5ml/kg/hour, usually indicative of renal dysfunction/failure
What is anuria?
Absolute anuria - no urine output
Relative anuria - < 100ml/24 hours
What is polyuria?
Urine output > 3l/24 hours
What is nocturne?
Waking up at night on one or more occasion to micturate
What is nocturnal polyuria?
Nocturnal urine output > 1/3rd of total urine output in 24 hours
What are the different natures of renal diseases?
Infection e.g. pyelonephritis
Inflammation e.g. glomerulonephritis, tubulointerstitial nephritis
Iatrogenic e.g. nephrotoxicity
Neoplasia e.g. renal tumours, collecting system tumours
Trauma
Vascular e.g. atherosclerosis, hypertension
Hereditary e.g. polycystic kidney disease, nephrotic syndrome
What are the main presentations of renal diseases?
Pain Pyrexia Haematuria Proteinuria Pyuria Mass on palpation Renal failure
What are the components of the RIFLE staging criteria?
Risk Injury Failure Loss End-stage kidney disease
According to the RIFLE staging criteria, what indicates risk of acute renal failure?
Increase in serum creatinine level (1.5x)
Decrease in GFR by 25%
UO < 0.5 ml/kg/hour for 6 hours
According to the RIFLE staging criteria, what indicates acute renal injury?
Increase in serum creatinine level (2.0x)
Decrease in GFR by 50%
UO < 0.5 ml/kg/hour for 12 hours
According to the RIFLE staging criteria, what indicates acute renal failure?
Increase in serum creatinine level (3.0x)
Decrease in GFR by 75%
UO < 0.3 ml/kg/hour for 24 hours, or anuria for 12 hours
Serum creatinine level > 355 umol/l with acute increase of > 44 umol/l
According to the RIFLE staging criteria, what indicates acute renal failure?
Persistent acute renal failure or complete loss of kidney function > 4 weeks
According to the RIFLE staging criteria, what indicates end-stage kidney disease?
Complete loss of kidney function > 3 months
What is the presentation of chronic renal failure in terms of body fluid homeostasis?
Fluid overload
Peripheral oedema
Congestive cardiac failure
Pulmonary oedema
What is the function of the kidneys in relation to regulation of vascular tone?
Regulation of blood pressure
What is the excretory function of the kidneys?
Physiological waste excretion, especially urea
Excretion of drugs
What are the endocrine functions of the kidneys?
Erythropoietin
Vitamin D metabolism
Renin
What is the presentation of chronic renal failure?
Asymptomatic - may be found coincidentally Fatigue Anaemia Oedema Hypertension Bone pain due to renal bone disease
What is the presentation of advanced renal failure?
Pruritis Nausea/vomiting Dyspnoea Pericarditis Neuropathy Coma in untreated advanced renal failure
What are the natures of ureteric diseases?
Infection e.g. ureteritis
Iatrogenic/trauma e.g. accidental damage in hysterectomy
Neoplasia e.g. urothelial carcinoma
Hereditary e.g. PUJ obstruction
Obstruction - intra-luminal (stone, clot), intra-mural (scar tissue), extra-luminal (pelvic mass)
What is the presentation of ureteric diseases?
Pain Pyrexia Haematuria Palpable mass (hydronephrosis) Renal failure (if there is bilateral obstruction or a single functioning kidney)
What are the natures of bladder diseases?
Infection e.g. cystitis
Inflammation e.g. interstitial cystitis
Iatrogenic/trauma e.g. bladder rupture, bladder injury from hysterectomy
Neoplasia e.g. transitional cell carcinoma
Idiopathic e.g. overactive bladder syndrome
Degenerative e.g. chronic urinary retention
Neurological e.g. neurogenic bladder dysfunction
What is the presentation of bladder diseases?
Pain (suprapubic) Pyrexia Haematuria Lower urinary tract symptoms - storage LUTS e.g. frequency, or voiding LUTS e.g. poor flow Incontinence Recurrent UTIs Chronic urinary retention Urinary leak from vagina i.e. vesico-vaginal fistula Pneumaturia i.e. coli-vesical fistula
What are the lower urinary tract symptoms?
Storage
- frequency
- nocturia
- urgency
- urge incontinence
Voiding
- poor flow
- intermittency
- terminal dribbling due to underachieve bladder
What are the main causes of lower urinary tract symptoms?
Bladder pathology e.g. overactive bladder, UTI
Bladder outflow obstruction
Pelvic floor dysfunction
Neurological causes
Systemic disorders e.g. cardiac failure, CRF
What are the neurological causes of lower urinary tract symptoms?
Supra-pontine lesions e.g. stroke, Alzheimer’s disease, Parkinson’s disease
Infra-pontine supra-sacral lesions e.g. spinal cord injury, disc prolapse
Intra-sacral e.g. MS, diabetes, cauda equina compression
What are the components of micturition control?
Cortical centre - bladder sensation and conscious inhibition of micturition
Pons - micturition centre
Sacral segments S2-S4 - micturition reflex, relaxation of internal urethral sphincter
Micturition cycle - storage phase, voiding phase
What are the natures of bladder outflow tract diseases?
Infection/inflammation e.g. prostatitis, balanitis
Iatrogenic/trauma e.g. pelvic floor damage after vaginal delivery, urethral injury from catheterisation
Neoplasia e.g. prostate/penile cancer
Idiopathic e.g. chronic pelvic pain syndrome
Obstruction e.g. benign prostatic enlargement, urethral stricture
What is the presentation of bladder outflow tract diseases?
Pain - suprapubic or perineal Pyrexia Haematuria Lower urinary tract symptoms Recurrent UTIs Acute urinary retention Chronic urinary retention
What is required to make a diagnosis of urinary tract infection?
Microbiological evidence and symptoms/signs
Microbiological evidence - bacterial count of 10^4 cfu/ml from MSSU specimen with no more than two species of micro-organism
Symptoms/signs - at least one of:
- fever > 38 degrees celsius
- loin/flank pain or tenderness
- suprapubic pain or tenderness
- urinary frequency
- urinary urgency
- dysuria
What are the two types of UTI?
Complicated and uncomplicated
Who typically gets uncomplicated UTIs?
Young, sexually active females with a clear relation to sexual activity
What factors should be considered when differentiating between complicated and uncomplicated UTI?
Age
Sexual activity in females
Gender
Co-morbidities e.g. immunosuppression, renal failure
Abnormal renal tract e.g. stones, renal outflow obstruction
Foreign body e.g. catheter, ureteric stent
Type of organisms e.g. common vs uncommon
What is the specific name for a urinary tract infection involving the:
- bladder
- prostate
- kidney
- testis
Bladder - cystitis
Prostate - prostatitis
Kidney - pyelonephritis
Testis - orchitis
What is a recurrent UTI?
Defined as > 3 UTIs per year or > 2 in 6 months
What is a relapsing UTI?
Defined as UTI caused by the same organism within 2 weeks of the preceding UTI, usually indicative of inadequately treated UTI
What are the potential complications of UTI?
Infective - sepsis, perinephric abscess Renal failure - scarring Bladder malignancy Acute urinary retention Frank haematuria Bladder or renal stones
What are the investigations that can be done for UTI?
MSSU/CSU
Lower tract - flow studies, residual bladder scan, cystoscopy
Upper tract - USS kidneys, IVU/CT KUB, MAG-3 renogram, DMSA scan
What is the treatment of UTI?
Appropriate antibiotics
Treat any underlying cause and complications
What is acute urinary retention?
Defined as a painful inability to void with a palpable and permissible bladder
What is the variation in residuals in acute urinary retention?
From 500ml to > 1L, depending on time taken to seek medical attention
What is the main risk factor of acute urinary retention?
Benign prostatic obstruction
It can also occur independently of this e.g. in UTIs, urethral stricture, alcohol excess, post-operatively, acute surgical/medical problems etc.
How does acute urinary retention occur with benign prostatic obstruction?
Can occur spontaneously i.e. as a natural progression or can be triggered by an unrelated event e.g. constipation, alcohol excess
What is the treatment of acute urinary retention?
Immediate treatment is catheterisation
If a trigger is present this should be treated
If due to BPE and no renal failure is present then alpha-blocker should be started immediately and catheter removed in 2 days (60% will void successfully at this point), if there is still a failure to void then re-catheterisation should be done and TURP organised
What complications might develop if acute urinary retention is left untreated?
UTI Post-decompression haematuria Pathological diuresis Renal failure Electrolyte abnormalities
What is chronic urinary retention?
Defined as painless, palpable and permissible bladder after voiding
Patients are often able to void but have residuals ranging from 400ml to > 2 litres, depending on the stage of their condition
What is the main etiological factor in chronic urinary retention?
Detrusor muscle under activity, which can be primary or secondary
How does chronic urinary retention present?
As lower urinary tract symptoms or as complications
What complications occur at the severe end of the spectrum of chronic urinary retention?
Overflow incontinence
Renal failure
What are the features of the severe end of the spectrum of chronic urinary retention?
Bladder capacity is reached and bladder pressure is in excess of 25cm water i.e. decompensated chronic urinary retention or acute-on-chronic urinary retention or chronic high-pressure urinary retention
What is the treatment of chronic urinary retention?
Immediate treatment is catheterisation, either urethral or suprapubic initially, followed by CISC
Subsequent treatment is with either long-term urethral or suprapubic catheter, CISC or TURP if due to BPE
What are the complications of chronic urinary retention?
UTI
Post-decompression haematuria
Pathological diuresis
Electrolyte abnormalities e.g. hyponatraemia, hyperkalaemia, metabolic acidosis
Persistent renal function due to acute tubular necrosis
What are the features of pathological diuresis?
Urine output > 200ml/hour
Postural hypotension
Weight loss
electrolyte abnormalities
What is the management of pathological diuresis?
Manage with IV fluids and close monitoring
What are the common clinical emergencies related to urinary tract diseases?
Acute renal failure
Sepsis due to UTI +/- upper or lower urinary tract obstruction
Renal colic
Severe haematuria causing haemorrhagic shock
Metastatic diseases causing metabolic derangements
Acute urinary retention
Chronic high-pressure urinary retention
Iatrogenic injury/trauma to upper or lower urinary tracts, penis and testes
Testicular torsion
Paraphimosis
Priapism