Define upper urinary tract
Define lower urinary tract
Bladder outflow tract
What are the different nature of renal diseases?
(I, I, I, Now Try Very Hard)
Give an example for each (IIINTVH)
•Infection - pyelonephritis
•Inflammation - glomerulonephritis, tubulointerstitial nephritis
•Iatrogenic - nephrotoxicity, PCNL (percutaneous nephrolithotomy - the removal of kidney stones)
•Neoplasia - renal tumours, collecting system tumours
•Trauma - blunt trauma
•Vascular - atherosclerosis, hypertension, diabetes
•Hereditary - polycystic kidney disease, nephrotic syndrome
What is the presentation of renal disease?
•Pyuria (pus in urine)
•Mass on palpation
(Peter, Piper, Previously, Made, Hillarious, Russian, Patter)
What is the definition of proteinuria?
Presence of protein in the urine
What are the types of haematuria?
What is the definition of microscopic haematuria?
Less than or equal to 3 red blood cells per high power field
What is the definition of oliguria, anuria, polyuria, nocturia, nocturnal polyuria
1.Oliguria: Urine output <0.5ml/kg/hour
2.Anuria: Absolute anuria - No urine output; Relative anuria - <100ml/24 hours
3.Polyuria: Urine output >3L/24 hours
4.Nocturia: Waking up at night ≥1 occasion to micturate
5.Nocturnal polyuria: Nocturnal urine output >1/3 of total urine output in 24 hours
What are the stages of acute kidney injury?
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
What are the functions of the kidney?
Body fluid homeostasis
Regulation of vascular tone
What are the endocrine functions of the kidney?
Vitamin D metabolism
What are the excretory functions of the kidney?
Physiological waste (urea)
What is the body fluid homeostasis role of the kidney?
Fluid overload (peripheral oedema, congestive heart failure, pulmonary oedema)
What electrolytes are controlled by the kidney?
What are the acid base homeostasis functions of the kidney?
What is the presentation of chronic renal failure?
•Asymptomatic (found on blood and urine testing)
•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)
What are the differing natures of ureteric diseases - give examples
•Infection - ureteritis
•Iatrogenic/Trauma - inadvertently cut or tied during hysterectomy or colon resection
•Neoplasia - TCC (transitional cell carcinoma) of ureter, TCC of bladder obstructing VUJ (vesico - ureteric junction), prostate cancer obstructing VUJ, pelvic malignancy, pelvic or para-aortic lymphadenopathy
•Hereditary - PUJ obstruction, VUJ reflux
•Obstruction - intra-luminal (stone, blood clot)
- intra-mural (scar tissue, TCC)
- extra-luminal (pelvic mass, lymph nodes)
What is the presentation of ureteric diseases?
•Pain (eg. renal colic)
•Palpable mass (ie. hydronephrosis)
•Renal failure (only if bilateral obstruction or single functioning kidney)
What is the nature of bladder disease?
•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
What is the presentation of bladder disease?
•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.)
•Chronic urinary retention (due to bladder underactivity)
•Urinary leak from vagina (i.e. vesico-vaginal fistula)
•Pneumaturia (i.e. colo-vesical fistula)
What are lower urinary tract symptoms?
Lower urinary tract symptoms (LUTS)refer to a group of clinical symptoms involving the bladder, urinary sphincter, urethra, and, in men, the prostate.
What are the storage LUTS?
Increased frequency of urination
Increased urgency of urination
Excessive passage of urine at night
What are the voiding LUTS?
Poor stream (unimproved by straining)
Hesitancy (worsened if bladder is very full)
Overflow incontinence (occurs in chronic retention)
Episodes of near retention
What are the causes of LUTS?
Bladder outflow obstruction
Pelvic floor dysfunction
Neurological causes - neurogenic bladder dysfunction
Systemic disorders - chronic renal failure, cardiac failure, diabetes mellitus, diabetes insipidus
What aspects of micturition is the cortical centre responsible for?
Inhibition of micturition
What part of the brain is described as the micturition centre?
What is the nature of bladder outflow tract diseases?
•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
What is the presentation of bladder outflow tract diseases?
•Pain (suprapubic or perineal)
•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
•Acute urinary retention
•Chronic urinary retention
What is acute urinary retention and what is the primary risk factor?
Painful inability to void with a palpable and percussible liver
Benign prostatic obstruction is the main risk factor (others include UTI, urethral stricture)
What can trigger benign prostatic obstruction?
Can happen simultaneously or can be triggered
Triggered by constipation, alcohol excess, post-operative, urological procedure
What is the treatment for urinary retention?
What are the complications of acute urinary retention?
Post - decompression haematuria
What is chronic urinary retention described as?
•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)
What causes chronic urinary retention?
Either primary bladder failure (failure of contraction of the detrusor muscle)
As a result of bladder outflow obstruction - BPO, urethral stricture
What is the presentation of chronic urinary retention?
•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)
What is the treatment for chronic urinary retention?
Catheterisation (urethral or suprapubic) followed by CISC if appropriate
Clean, intermittant, self cathaterisation
Treatment for chronic urinary retention caused by BPO is TURP - Transurethral resection of the prostate
What are the complications of chronic urinary retention?
•Complications: UTI, post-decompression haematuria, pathological diuresis, electrolyte abnormalities (hyponatraemia, hyperkalaemia, metabolic acidosis), persistent renal dysfunction due to acute tubular necrosis
What is the definition of a UTI?
•Defined as infection affecting urinary tract (including kidneys, bladder, prostate, testis and epididymis)
How is the diagnosis of a UTI made?
Microbiological evidence: Bacterial count of 105 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
What are the two types of UTI?
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
What are the complications of UTI?
- infective: sepsis (esp. pyelonephritis), perinephric abscess
- renal failure (scarring)
- bladder malignancy (squamous cell carcinoma)
- acute urinary retention
- frank haematuria
- bladder or renal stones
What are the investigations for UTI?
MSSU/CSU (mid stream specimen urine/catheter specimen urine)
- 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 antibiotic therapy (type? duration? route?) - usually trimethoprim
- Treat complications and cause
What are emergencies related to urinary tract diseases?
•Acute renal failure
•Sepsis due to UTI +/- upper or lower urinary tract obstruction
•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
•Paraphimosis - foreskin of the penis, once retracted, cannot return to its original location
•Priapism - painful and persistent erection of the penis