Presentation of Diseases of the Kidneys and Urinary Tract 2020 pre-lecture version

Question 1

what makes up the upper urinary tract?

Answer 1

1. Kidneys
   - Parenchyma
   - Pelvi-calyceal system
2. Ureters
   - Pelvi-ureteric junction
   - Ureter
   - Vesico-ureteric junction

Question 2

what makes up the lower urinary tract?

Answer 2

1. Bladder
2. Bladder outflow tract
   - Bladder neck (intrinsic urethral sphincter)
   - Prostate
   - External urethral sphincter/pelvic floor
   - Urethra
   - Urethral meatus
   - Foreskin

Question 3

study this picture showing the anatomy of the kidney

Upper urinary tract disease: Kidney

Answer 3

Question 4

what is in a surgical sieve?

Answer 4

• Infection
• Inflammation
• Iatrogenic
• Neoplasia
• Trauma
• Degenerative
• Congenital
• Genetic/Hereditary
• Vascular
• Endocrine
• Failure
• Idiopathic
• Etc.

Question 5

what may the nature of renal diseases be?

Answer 5

• Infection
• Inflammation
• Iatrogenic
• Neoplasia
• Trauma
• Vascular
• Hereditary

Question 6

nature of renal diseases:

what is an exmaple of infection?

Answer 6

•pyelonephritis

Question 7

nature of renal diseases:

what is an exmaple of inflammation?

Answer 7

•glomerulonephritis, tubulointerstitial nephritis

Question 8

nature of renal diseases:

what is an exmaple of iatrogenic?

Answer 8

nephrotoxicity, PCNL (surgery to remove stones form the kidney, drill big hole into the kidneys and can cause damage)

Question 9

nature of renal diseases:

what is an exmaple of neoplasia?

Answer 9

renal tumours, collecting system tumours

Question 10

nature of renal diseases:

what is an exmaple of trauma?

Answer 10

blunt trauma

Question 11

nature of renal diseases:

what is an exmaple of vascular origin?

Answer 11

atherosclerosis, hypertension, diabetes

Question 12

nature of renal diseases:

what is an exmaple of heriditary cause?

Answer 12

polycystic kidney disease, nephrotic syndrome

Question 13

what is the presentation of renal diseases?

Answer 13

• Pain
• Pyrexia
• Haematuria
• Proteinuria
• Pyuria
• Mass on palpation
• Renal failure

Question 14

1. What is the definition of proteinuria?
   a. Presence of protein in urine
   b. Presence of albumin in urine
   c. Urinary protein excretion >1mg/day
   d. Urinary protein excretion >150mg/day
   e. Urinary protein excretion >15g/day

Answer 14

Everyone secretes protein in urine so cant be A

Answer = D

Question 15

2. How many types of haematuria are there?
   a. One
   b. Two
   c. Three
   d. Four
   e. Five

Answer 15

Macroscopic – gross or frank haematuria

Microscopic – examined under microscope and can see the cells

Dipstick positive haematuria

Answer = C

Question 16

3. The definition of microscopic haematuria is:
   a. ≥1 red blood cells per high power field
   b. ≥2 red blood cells per high power field
   c. ≥3 red blood cells per high power field
   d. ≥4 red blood cells per high power field
   e. ≥5 red blood cells per high power field

Answer 16

Answer = C

Question 17

Urine output: Definitions:

What is Oliguria?

Answer 17

Urine output <0.5ml/kg/hour

Question 18

Urine output: Definitions:

What is Anuria?

Answer 18

Absolute anuria - No urine output; Relative anuria - <100ml/24 hours

failure of the kidneys to produce urine

Question 19

Urine output: Definitions:

What is Polyuria?

Answer 19

Urine output >3L/24 hours

Question 20

Urine output: Definitions:

What is Nocturia?

Answer 20

Waking up at night ≥1 occasion to micturate

Question 21

Urine output: Definitions:

What is Nocturnal polyuria?

Answer 21

Nocturnal urine output >1/3 of total urine output in 24 hours

Question 22

Acute Kidney Injury (AKI) (ARF) - what is the definiton in terms of staging?

Answer 22

1. Risk - Increase in serum creatinine level (1.5x) or decrease in GFR by 25%, or UO <0.5 mL/kg/h for 6 hours
2. Injury - Increase in serum creatinine level (2.0x) or decrease in GFR by 50%, or UO <0.5 mL/kg/h for 12 hours
3. Failure - Increase in serum creatinine level (3.0x), or decrease in GFR by 75%, or serum creatinine level >355μmol/L with acute increase of >44μmol/L; or UO <0.3 mL/kg/h for 24 hours, or anuria for 12 hours
4. Loss - Persistent ARF or complete loss of kidney function >4 weeks
5. End-stage kidney disease - complete loss of kidney function >3 months

Question 23

presentation of chronic renal failure - what are the functionns of the kidneys?

Answer 23

Question 24

one function of the kidney is body fluid homeostasis, what is an example of this?

Answer 24

fluid overload (peripheral oedema, congestive cardiac failure, pulmonary oedema)

Question 25

one function of the kidney is electrolyte homeostasis, name examples of this?

Answer 25

Na+ K+ Cl- etc

Question 26

one function of the kidney is acid-base homeostasis, name examples of this?

Answer 26

excrete H+ generate HCO3-

Question 27

one function of the kidney is regulation of vascular tone, what is an example of this?

Answer 27

regulation of blood pressure

Question 28

one function of the kidney is regulation of excretory functions, what is an example of this?

Answer 28

physiological waste (esp. urea) drugs

Question 29

one function of the kidney is endocrine functions, what are examples of this?

Answer 29

erythropoeitin vitamin D metab renin

Question 30

what is the presentation of chronic renal failure?

Answer 30

* Asymptomatic (found on blood and urine testing) * Tiredness * Anaemia * Oedema * High blood pressure * Bone pain due to renal bone disease * Pruritus (in advanced renal failure) * Nausea/vomiting (in advanced renal failure) * Dyspnoea (in advanced renal failure) * Pericarditis (in advanced renal failure) * Neuropathy (in advanced renal failure) * Coma (untreated advanced renal failure)

Question 31

what are the different natures of ureteric diseases?

Answer 31

infection iatrogenic/trauma neoplasia hereditary obstruction

Question 32

the nature of ureteric disease may be infection, what is an example of this?

Answer 32

ureteritis

Question 33

the nature of ureteric disease may be iatrogenic/trauma, what is an example of this?

Answer 33

inadvertently cut or tied during hysterectomy or colon resection

Question 34

the nature of ureteric disease may be neoplasia, what are examples of this?

Answer 34

TCC of ureter, TCC of bladder obstructing VUJ, prostate cancer obstructing VUJ, pelvic malignancy, pelvic or para-aortic lymphadenopathy

Question 35

the nature of ureteric disease may be hereditary, what are examples of this?

Answer 35

PUJ obstruction, VUJ reflux

Question 36

the nature of ureteric disease may be obstruction, what are examples of this?

Answer 36

intra-luminal (stone, blood clot) intra-mural (scar tissue, TCC) extra-luminal (pelvic mass, lymph nodes)

Question 37

what is the presentation of ureteric diseases?

Answer 37

* Pain (eg. renal colic) * Pyrexia * Haematuria * Palpable mass (ie. hydronephrosis) * Renal failure (only if bilateral obstruction or single functioning kidney)

Question 38

what is the nature of bladder disease?

Answer 38

* Infection - cystitis * Inflammation - interstitial cystitis, colonic diverticulitis resulting in colo-vesical fistula * Iatrogenic/Trauma - bladder rupture, bladder injury from hysterectomy (resulting in vesico-vaginal fistula) * Neoplasia - TCC of bladder, squamous cell carcinoma of bladder * Idiopathic - overactive bladder syndrome * Degenerative - chronic urinary retention * Neurological - neurogenic bladder dysfunction

Question 39

what is the presentation of bladder diseases?

Answer 39

* Pain (suprapubic) * Pyrexia * Haematuria * Lower urinary tract symptoms (LUTS) - storage LUTS (i.e. frequency, nocturia, urgency, urge incontinence) - voiding LUTS (i.e. poor flow, intermittency, terminal dribbling) – due to underactive bladder - incontinence (stress, urge, mixed, overflow, neurogenic, dribbling, etc.) * Recurrent UTIs * Chronic urinary retention (due to bladder underactivity) * Urinary leak from vagina (i.e. vesico-vaginal fistula) * Pneumaturia (i.e. colo-vesical fistula)

Question 40

1. What is the risk of bladder cancer in a patient who presents with frank haematuria? a. 10-15% b. 15-20% c. 20-25% d. 25-30% e. 30-35%

Answer 40

D

Question 41

2. What is the risk of renal cancer in a patient who presents with frank haematuria? a. 0-0.5% b. 0.5-1.0% c. 5-10% d. 10-20% e. 20-25%

Answer 41

C

Question 42

what is shown here?

Answer 42

Endoscopic view of superficial TCC of bladder

Question 43

Specimen of Bladder with solid TCC

Answer 43

Question 44

Lower urinary tract symptoms (LUTS) (i.e. voiding LUTS, storage LUTS, incontinence, polyuria, etc.) can have multitude of causes, what are they?

Answer 44

- bladder pathology (OAB, UTI, interstitial cystitis, bladder cancer) - bladder outflow obstruction - pelvic floor dysfunction - neurological causes (i.e. neurogenic bladder dysfunction): i. supra-pontine lesions (e.g. stroke, Alzheimer’s, Parkinson’s) ii. infra-pontine supra-sacral lesions (e.g. spinal cord injury, disc prolapse, spina bifida) iii. infra-sacral (e.g. multiple sclerosis, diabetes, cauda equina compression, surgery to retroperitoneum) - systemic disorders (e.g. chronic renal failure, cardiac failure, diabetes mellitus, diabetes insipidus)

Question 45

what is the control of micturation done by?

Answer 45

1) Cortical centre (bladder sensation and conscious inhibition of micturition) 2) Pons (micturition centre) - main centre controlling voiding 3) Sacral segments (S2-S4) (micturition reflex): - relaxation of internal urethral sphincter (autonomic - sympathetic) - relaxation of external urethral sphincter (somatic) - contraction of detrusor muscle (autonomic – parasympathetic)

Question 46

What are the phases of the micturition cycle?

Answer 46

1) Storage (or filling) phase 2) Voiding phase

Question 47

What are the different natures of bladder outflow tract diseases?

Answer 47

* Infection/Inflammation - prostatitis, balanitis * Iatrogenic/Trauma - pelvic floor damage after traumatic vaginal delivery or hysterectomy, urethral injury from catheterisation or pelvic fracture * Neoplasia - prostate cancer, penile cancer * Idiopathic - chronic pelvic pain syndrome * Obstruction: - primary bladder neck obstruction - benign prostatic enlargement (BPE) causing obstruction - urethral stricture - meatal stenosis - phimosis

Question 48

what are the presentations of bladder outflow tract diseases?

Answer 48

* Pain (suprapubic or perineal) * Pyrexia * Haematuria * Lower urinary tract symptoms (LUTS) - voiding LUTS (i.e. hesitancy, intermittency, poor flow, terminal dribbling, incomplete bladder emptying) due to Bladder Outflow Obstruction (BOO) - overflow incontinence (high-pressure chronic urinary retention) - stress urinary incontinence * Recurrent UTIs * Acute urinary retention * Chronic urinary retention

Question 49

what is acute urinary retention?

Answer 49

Defined as ‘painful inability to void with a palpable and percussible bladder' Residuals vary from 500ml to 1 litre (but usually \<1 litre)

Question 50

what is the main risk factor for acute urinary retention?

Answer 50

Main risk factor is Benign Prostatic Obstruction (BPO) but can also occur independently of BPO (eg. UTI, urethral stricture, alcohol excess, post-operative causes, acute surgical or medical problems) •For those with BPO, usually triggered by an unrelated event (eg. constipation, alcohol excess, post-operative causes, urological procedure)

Question 51

what is the treatment for acute urinary retention?

Answer 51

* Immediate treatment is catheterisation (either urethral or suprapubic) * Treat underlying trigger if present

Question 52

what is chronic urinary retention?

Answer 52

* Defined as ‘painless, palpable and percussible bladder after voiding’ * Patients often able to void but with residuals ranging from 400ml to \>2 litres depending on stage of condition (i.e. wide spectrum)

Question 53

what causes chronic urinary retention and how does it present?

Answer 53

* Main aetiological factor is detrusor underactivity which can be primary (i.e. primary bladder failure) or secondary (i.e. due to longstanding BOO, such as BPO or urethral stricture) * Presents as LUTS or complications (e.g. UTI, bladder stones, overflow incontinence, post-renal or obstructive renal failure) or incidental finding * Overflow incontinence and renal failure occur at severe end of spectrum, when bladder capacity is reached and bladder pressure is in excess of 25cm water (i.e. chronic high-pressure urinary retention)

Question 54

What is the treatment of chronic urinary retention?

Answer 54

* Asymptomatic patients with low residuals do not necessarily need treatment * Patients with symptoms or complications need treatment (but no role for medical therapy!) * Immediate treatment is catheterisation (either urethral or suprapubic initially, followed by CISC if appropriate)

Question 55

what are complications of chronic urinary retention?

Answer 55

UTI, post-decompression haematuria, pathological diuresis, electrolyte abnormalities (hyponatraemia, hyperkalaemia, metabolic acidosis), persistent renal dysfunction due to acute tubular necrosis

Question 56

If high-pressure chronic urinary retention, two types of diuresis may occur, what are they?

Answer 56

Physiological (usually \<200ml/hour) Pathological (usually \>200ml/hour)

Question 57

what is a UTI?

Answer 57

Defined as infection affecting urinary tract (including kidneys, bladder, prostate, testis and epididymis)

Question 58

how do you diagnose a UTI?

Answer 58

• A diagnosis requires microbiological evidence AND symptoms/signs: i. Microbiological evidence: Bacterial count of 104 cfu/ml from MSSU specimen with no more than two species of micro-organisms ii. Symptoms/signs: At least one of the following: Fever \>38ºC; loin/flank pain or tenderness; suprapubic pain or tenderness; urinary frequency; urinary urgency; dysuria

Question 59

what are the 2 types of UTIs?

Answer 59

i. Uncomplicated UTIs (young sexually active females only with clear relation to sexual activity) ii. Complicated UTIs (everyone else!) • Complicated UTIs always need to be investigated

Question 60

What are some factors to consider in differentiating between complicated vs uncomplicated UTI?

Answer 60

- Age - Sexual activity (females) - Gender - Co-morbidities (e.g. immunosuppression, renal failure, medications) - Abnormal renal tract (e.g. stones, renal outflow obstruction, BOO, horseshoe kidney, VU reflux, renal scarring, bladder tumour) - Foreign body (e.g. catheter, ureteric stent) - Type of organisms (E. coli, Staph. saprophyticus, Klebsiella, Proteus, Pseudomonas, Staph aureus)

Question 61

what does the presentation of UTIs depend on?

Answer 61

• Presentation depends on organ affected - bladder (cystitis); prostate (prostatitis); kidney (pyelonephritis); testis (orchitis)

Question 62

whata re complications of UTI?

Answer 62

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

Question 63

what are the investigations for UTI?

Answer 63

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

Question 64

what is the treatment of UTI?

Answer 64

- Appropriate antibiotic therapy (type? duration? route?) - Treat complications and cause

Question 65

what are some emergencies related to UTI?

Answer 65

* Acute renal failure * Sepsis due to UTI +/- upper or lower urinary tract obstruction * Renal colic * Severe haematuria causing haemorrhagic shock * Metastatic disease causing metabolic derangements (eg. hypercalcaemia from bony metastases), spinal cord compression from vertebral metastases, etc. * Acute urinary retention * Chronic high-pressure urinary retention * Iatrogenic injury/Trauma to upper or lower urinary tracts, penis and testis * Testicular torsion * Paraphimosis - Foreskin comes back and cant go forward again and causes ischemia * Priapism - erection over 4 hours after sexual activity

Question 66

1. The following are essential features of acute urinary retention except: a. painful b. palpable bladder c. inability to urinate d. bladder volume \>800ml e. percussible bladder

Answer 66

D

Question 67

2. The following organisms are commonly associated with urinary tract infections except: a. E. coli b. Klebsiella species c. Proteus species d. Chlamydia trachomatis e. Pseudomonas aeruginosa

Answer 67

top 3 are coliforms Chlamydia is a sexual transited disease E is an opportunistic organism D is the correct answer