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Urology > Urinary > Flashcards

Urinary Flashcards

1
Q

Name 4 symptoms and signs of upper urinary tract obstruction

A
  • loin to groin /flank pain on affected side due to stretching and irritation of ureter and kidney
  • reduced or no urine output
  • nonspecific symptoms eg vomiting
  • impaired renal function on bloods (raised creatinine )
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2
Q

Name 3 symptoms of lower urinary tract obstruction

A
  • Difficulty / inability to pass urine eg poor flow, difficulty initiating urination, terminal dribbling.
  • urinary retention with increasingly full bladder
  • impaired renal function on bloods ie raised creatinine
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3
Q

Name 6 common causes upper urinary tract obstruction

A

. Kidney stones
. Tumours pressing on ureters
• ureter strictures (due to scar tissue narrowing the tube)
• retroperitoneal fibrosis ( development of scar tissue in retroperitoneal space)
• bladder cancer blocking ureteral openings to bladder
• ureterocoele - ballooning most distal portion ureter, usually congenital

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4
Q

Name 5 common causes lower urinary tract obstruction

A 
• Benign prostatic hyperplasia
. Prostate cancer
. Bladder cancer (blocking neck of bladder)
• urethral strictures due to scar tissue
• neurogenic bladder
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5
Q

Name 7 complications obstructive uropathy

A
  • Pain
  • AKI post-renal
  • CKD
  • infection from bacteria tracking up urinary tract into areas of stagnated urine
  • hydronephroses - swelling of renal pelvis and calyces in kidney
  • urinary retention and bladder distention
  • overflow incontinence of urine
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6
Q

What is Desmopressin used for?

A

Enuresis

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7
Q

! Define enuresis

A

Persistence of involuntary voiding of urine beyond age of anticipated control ie bedwetting > 2 times per month in child ≥5

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8
Q

Classification enuresis?

A
  • Primary: child has never successfully controlled urination
  • secondary: recurrence of incontinence after being dry for > 6 months. Usually in response to some sort of stressful situation
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9
Q

Name 7 causes nocturnal enuresis

A

• vast majority no physical or mental abnormality!
• sleep disorders!: deep sleepers, disorder of arousal, OSA
• nocturnal polyuria!: due to decreased ADH.
• decreased functional bladder capacity!
• developmental delay of CNS
• genetic factors
• Psychology. Eg anxiety
. Bladder detrusor/sphincter dysfunction.

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10
Q

Name 9 causes enuresis in adults

A
  • Bladder cancer
  • diabetes
  • medication side effects eg tricyclic antidepressants, alpha blockers in females
  • neurological disorders eg spinal cord injury, meningomyelocele, cerebrovascular accident, Parkinson’s etc
  • OSA
  • prostate cancer
  • prostate enlargement
  • UTI
  • ut stones
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11
Q

Define diurnal enuresis

A

Daytime accidental wetting in children

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12
Q

Name 4 causes diurnal enuresis in children

A
  • Overactive bladder
  • inadequate voiding
  • small bladder capacity
  • constipation
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13
Q

Which special examinations can be performed for enuresis? (3)

A
  • Nb if monosymptomatic enuresis (nocturnal wetting with no other urinary symptoms) with normal examination and normal urinalysis, no special investigation indicated!
  • If UTI: do ultrasound and indirect cystogram (to exclude vesico-ureteric reflux)
  • If day time symptoms or suspect neuropathic bladder: ultrasound. If trabeculated bladder and or hydronephrosis, do MCUG and UDS (urodynamic studies)
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14
Q

Treatment enuresis? (6)

A

First line = lifestyle
• fluid restrict before bedtime,
• walking child at night to void,
. bladder diary to monitor progress and diagnose nocturnal polyuria.
• star charts
• conditioning therapy by enuresis alarm most effective! To inhibit micturition reflex, take a month

Second line = pharmacotherapy
• not recommended before age 7
• desmopressin preferred (vasopressin- ADH analogue to decrease urine output)
• imipramine (TCA): lighten sleep level, anticholinergic on bladder, alpha-adrenergic on bladder neck
• anticholinergics: oxybutinin-only for day time symptoms

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15
Q

Name 7 causes pseudohaematuria

A

• vaginal bleeding
• dyes: beets, rhodamine B in candy and juices
• haemoglobin (haemolytic anemia )
• myoglobin (rhabdomyolysis)
• drugs (rifampin, phenazopyridine, phenytoin)
• porphyria
. Laxatives (phenolphthalein)

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16
Q

Name 6 infections / inflammatory causes haematuria

A
  • Pyelonephritis
  • Tb
  • cystitis
  • schistosomiasis
  • urethritis
  • glomerulonephritis (especially IgA nephropathy )
  • interstitial nephritis
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17
Q

Name 6 malignant causes haematuria

A

• renal cell carcinoma (adults)
• wilms’ tumour (paeds)
• urothelial cancer - ureter tumour, bladder cancer (most common cause painless macroscopic haematuria in older patient! ), urethra carcinoma
• prostate cancer
• leukemia.
!Haematuria = bladder cancer until proven other wise!

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18
Q

Name 3 benign causes haematuria

A

. BPH
• polyps
• exercise induced

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19
Q

Name 9 structural causes haematuria

A
  • Stones (renal, ureter, bladder )
  • Trauma eg catheter, TURP, TRUS,,
  • foreign body
  • urethral stricture
  • polycystic kidneys
  • vascular kidneys: renal vein thrombosis, arteriovenous fistula
  • infarct
  • hydronephrosis
  • fistula
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20
Q

Name 4 haematologic causes haematuria

A 
• Anticoagulants eg warfarin
• coagulation defects eg haemophilia
• sickle cell disease
. Leukemia
• thromboembolism
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21
Q

Why is the relationship between micturition and bleeding important in haematuria?

A
  • Initial haematuria: blood visible at beginning of micturition, then clears. Origin = urethra, especially prostatic
  • total haematuria: origin = upper tracts or bladder
  • terminal: origin= bladder or prostate. Classical presentation schistosomiasis (bilharzia) of bladder!
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22
Q

How can urological, haematological and nephrological causes of haematuria be differentiated on urinalysis? (3)

A

Nephrological
• 2-3+ proteinuria
• red cell casts or dysmorphic red cells on microscopy

Haematological and urological
• no proteinuria
• normal RBC
• no red cell casts, but white cell casts may be found in patient with acute pyelonephritis

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23
Q

Define haematuria

A

Passage of more than 3 RBCS/ HPF (high power field) on urine microscopy

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24
Q

Which investigations should be done in patients with haematuria? ( 7 )

A
  • Kidney, ureter, bladder ultrasound on all patients!
  • cystoscope in all patients! Except if low risk malignancy (<40, female, microscopic haematuria, non-smoker)
  • early morning urines if suspect urinary Tb
  • urine cytology if bladder or upper tract tumour suspected
  • urine microscopy for ova if schistosomiasis (bilharzia) suspected
  • CT scan if renal mass on ultrasound or suspected stone disease (renal colic symptoms )
  • haematological tests if haematological cause suspected eg INR if on anticoagulants
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25
Q

How describe light coloured urine medically?

A

Serous urine

26
Q

How describe dark coloured urine medically?

A

Sangiounous urine

27
Q

Describe the steps of the act of micturition (6)

A
  • Voluntary suppression of cerebral inhibition via cortical micturition centre in frontal cortex
  • increased intra-abdominal pressure via contraction diaphragm, abdominal wall muscles and pelvic floor
  • detrusor contraction by stimulation of efferent motor fibres (parasympathetic bladder centre s2-s4)
  • increase intravesical pressure → opening bladder neck
  • when intravesical pressure exceeds urethral pressure, distal sphincter mechanism opens and voiding occurs (inhibition sympathetic t11 - L2 and somatic pudendal nerve s2-s4)
  • voluntary relaxation of pelvic floor and striated urethral sphincter

• when bladder empty: detrusor relax, bladder neck close, urethral and perineal muscle tone return to normal

28
Q

Classification and etiologies neuropathic bladder? (5)

A

Failure to empty: lower motor neuron pathology at ( lesion below L1 )
• bladder centre spinal cord s2-s4 eg trauma
• efferent parasympathetic s2-s4 fibres eg gullain barre
• afferent. parasympathetic fibres eg diabetic autonomic neuropathy
• both efferent and efferent eg radical pelvic surgery

Failure to store: upper motor neuron lesion due to disease above bladder centre s2-s4 in spinal cord or cns (lesion above T12 )

29
Q

Name 7 clinical features of LMN neuropathic bladder

A 
• Overflow incontinence (failure to empty)
• urinary difficulty
• nocturnal enuresis
• bladder palpable, non-tender
• perianal sensation absent (S2-S4 affected)
• anal tone decreased
• bulbo-cavernosus reflex absent
• constipation or fecal incontinence
. ED
30
Q

Name 4 clinical features of UMN neuropathic bladder with disease above brainstem

A
  • Frequency and urgency (failure to store)
  • urge incontinence
  • bladder impalpable
  • normal examination of s 2,3,4 reflex arc
31
Q

Name 5 clinical features of UMN neuropathic bladder with suprasacral spinal lesion

A
  • Completely incontinent (reflex voiding)
  • bladder impalpable
  • bulbocavernosus reflex brisk
  • peri-anal sensation absent
  • anal tone increased
  • ED
  • fecal incontinence
32
Q

Which special investigations should be done for neurogenic bladder? (3)

A

• Renal function tests
• Ultrasound kidneys: rule out hydronephrosis (sign upper tract deterioration), stones (if found, do IVP/EUG)
• urodynamic studies!
- nb intravesical pressure: low pressure = safe bladder; high = unsafe (risk upper tract deterioration)
• MCUG: bladder capacity, wall smooth or trabeculated, exclude vUR

33
Q

Name 7 complications neurogenic bladder

A
  • Renal failure
  • calculi renal and bladder
  • recurrent UTI
  • VUR
  • urethral diverticulum and fistula due to long indwelling transurethral catheter
  • Scc bladder if catheter >10 years
  • autonomic dysreflexia: associated with injury above t6. Unopposed sympathetics. Bladder distension one of most common precipitating factors. Emergency, give iv nifedipine for bp
34
Q

Treatment LMN neuropathic bladder?

A

Clean intermittent self-catheterisation (cisc) or indwelling catheter if not possible

35
Q

Treatment UMN neuropathic bladder by CNS causes?

A

Anticholinergic’s eg oxybutinin, tolterodine

36
Q

Treatment UMN neuropathic bladder by spinal causes? ( 5)

A
  • CISC and anticholinergics eg oxybutinin, tolterodine
  • if refractory: botulinum toxin inject into bladder wall and CISC
  • external sphincterotomy to reduce outlet resistance and condom catheter
  • augmentation cystoplasty (segment of ileum or colon used to enlarge bladder volume ) and CISC
  • supravesical urinary diversion eg ileal conduit, continent diversion (last resort)
37
Q

Name 5 goals of treatment of neuropathic bladder

A

• Upper tract preservation or improvement
• prevent or control UTI
• adequate emptying. at low intravesical pressure
• urinary continent
.No indwelling catheter or stoma

38
Q

Name 5 hereditary risk factors urolithiasis

A 
•Rta (renal tubular acidosis)
• g6pd (glucose 6 phosphate dehydrogenase) deficiency
• cystinuria (stones from cysteine AA )
• xanthinuria
• oxaluria
Etc
39
Q

Name 5 lifestyle risk factors urolithiasis

A
  • Minimal fluid intake
  • excess vitamin C
  • excess oxalate (spinach, beetroot, sweet potato, soy, almonds)
  • excess purines (alcohol, anchovies and sardines, bacon, liver, raisins)
  • excess calcium ( dairy, broccoli, soybeans, )
40
Q

Name 4 medication risk factors urolithiasis

A
  • Loop diuretics: furosemide, bumetadine
  • acetazolamide (carbonic anhydrase inhibitor, lower blood ph)
  • topirimate
  • zonisamide (sulphonamide for epilepsy)
41
Q

Name 7 medical condition risk factors urolithiasis

A

• UTI with urea-splitting organisms: proteus, pseudomonas, providencia, klebsiella, mycoplasma, serratia, S aureus
• myeloproliferative disorders
• IBD
• gout
• dm
. Hypercalcaemia disorders: hyperparathyroid, tumour lysis syndrome, sarcoidosis, histoplasmosis
• obesity BMI >30

42
Q

Etiology and classification bladder calculus? (7)

A

Primary (endemic): usually children, associated with malnutrition and recurrent gastroenteritis (dehydration)

Secondary
• bladder outflow obstruction!
• Foreign bodies
- “egg shell” encrustations following indwelling catheters
- non-absorbable sutures eg colposuspension
-Inserted into urethra by patient
• stasis and infection
- Neuropathic bladder
-Bladder diverticulum
• stone from upper tract
• metabolic: primary hyperparathyroidism, cystinuria

43
Q

Clinical features bladder stones? (5)

A
  • Suprapubic pain, dysuria
  • haematuria usually terminal
  • intermittency due to occasional stone impaction at bladder neck- classic symptom!
  • bladder outflow obstruction symptoms
  • irritative symptoms due to secondary infection
44
Q

Diagnosis bladder calculus? (3)

A
  • Ultrasound
  • AXR: 50% non-opaque (don’t show up)
  • cystoscope incidental finding in patient with bladder outflow obstruction
45
Q

Treatment bladder stones? (2)

A
  • Endoscopic stone fragmentation: cystolitholapaxy

* open cystolithotomy if multiple stones, or open prostatectomy needed to treat bladder outflow obstruction

46
Q

Clinical features urethral stricture? (3)

A
  • Urinary difficulty: “Thin” stream, “spraying” of stream → suggest distal stricture, absence nocturia
  • submeatal or meatal stenosis
  • gonococcal strictures → periurethral fibrosis → thickening bulbar urethra palpable in perineum
  • palpable unethral mass and bleeding suggest carcinoma
  • complications of strictures, local and of outflow obstruction
47
Q

Investigations for urethral stricture? (5)

A

. Culture urine, UTI must be treated before urethrogram and treatment.
• flow rates <10 ml/s on uroflowmetry
• urethrogram!
- ascending (retrograde ): inject dye with urethral catheter 2-3 cm into urethra while X-ray screening to give information about anterior urethra
- descending voiding prograde/antegrade: bladder filled with contrast through suprapubic catheter pt then void under xray screening to give info about posterior urethra
- traumatic membranous injury needs simultaneous ascending and descending urethrogram to assess length of “gap’’’
(Cystoscopy)

48
Q

Treatment urethral stricture? (7 )

A

• Supra pubic cystostomy if present with any complications!

Minimally invasive
. Dilatation of urethra: retrograde instillation with topical local anaesthetic. Use filiforms and followers (preferred) or metal sounds eg lister’s dilators (complication= “false passage”). Risk bleeding, bactaeraemia/septicaemia, 50% recurrence.
• optical / visual internal urethrotomy (sachse procedure): for short < 2cm strictures in bulbar urethra. Use cystoscope with cold knife at tip and guidewire. Need Indwelling transurethral silastic catheter 1-3 days after. Risk bleeding, false passage, extravasation irrigating fluid into subcutaneous tissue causing infection , septicaemia; 50% recurrence
• intermittent self-dilatation with semi-stiff catheter to reduce recurrence
• urethral stent: expensive, contraindicated post-traumatic strictures

Urethroplasty: only potentially curative method
• excision and end-to-end urethroplasty: for any stricture < 2 cm, all post traumatic strictures
• substitution urethroplasty: part of wall substituted with free tissue graft eg buccal mucosa, or vascularised penile skin flap from shaft, or whole tube replaced with foreskin pedicle flap . indicated for longer strictures, usually inflammatory

49
Q

Classification of bladder rupture? (3)

A

Extraperitoneal
• always associated with pelvic #, usually direct penetration of bladder wall by bony fragment
• anterior or lateral bladder wall

Intraperitoneal
• When patient with full bladder sustains blow to lower abdomen
• “burst” type injury so large horizontal tear in dome of bladder

Spontaneous
• no history trauma
• due to underlying urological pathology: urethral stricture with chronic urinary retention, Tb cystitis, bladder carcinoma

50
Q

Clinical features traumatic bladder injury? (6)

A
  • Unable to void!
  • no sign of urethral injury, ie no blood at external urethral meatus
  • impalpable bladder
  • Urethral catheter → macroscopic haematiuria
  • abdominal tender, distension, peritonitis
  • suprapubic pain
51
Q

Definite investigation for bladder injury and features?

A

Ascending cystogram
Intraperitoneal rupture: extravasation of contrast diffusely in peritoneum cavity . In paracolic gutter
Extrapertoneal: most often pelvic #, contrast extravasation around base bladder, flame-shaped density adjacent to wall

52
Q

Treatment extraperitoneal bladder rupture? (4)

A

Most conservative because most small
• urethral catheter 10 days
• broad spectrum antibiotics
• repeat ascending cystogram in 10 days to check of healed

Surgery if: pt already having laparotomy for suspected intraperitoneal injury; associated injury to bladder neck , membranous urethra or rectum.

53
Q

Treatment intra peritoneal bladder rupture?

A

Always surgical because: (laparotomy)
• possibility bladder neck, ureter or vaginal injury
• 80% have associated intra-abdominal visceral damage, especially rectum.

54
Q

Injury to Which part of urethra is associated with fractured pelvis?

A

Membranous

55
Q

Injury to Which part of urethra is associated with direct perineal trauma?

A

Bulbar

56
Q

Name 5 complications urethral injuries

A
  • Stricture!
  • ED
  • fistula: urethro-rectal, urethrocutaneous
  • periurethral complications: urinary extravasation, periurethral abscess (ant urethra trauma), necrotising fasciitis of perineum, pelvis abscess (post urethra)
  • incontinence: post urethra injury, in children, uncommon
57
Q

Clinical presentation urethral trauma? (5)

A
  • Blood at urethral meatus - urethral bleeding
  • high riding prostate (boggy mass felt - pelvic haematoma) = serious injury with wide displacement
  • swelling and butterfly perineal haematoma with ant urethra injury
  • urinary retention,
  • penile and or scrotal haematoma, distended bladder
58
Q

Investigation of choice for suspected urethral injury?

A

Ascending retrograde urethrogram!

59
Q

Treatment blunt urethral trauma?

A

• Initial suprapubic cystostomy
. Descending urethrogram done 14 days later
• if show complete obstruction, do end - to end unethroplasty 3-6 mouths post injury

60
Q

Treatment penetrating urethral trauma?

A

Immediate surgical exploration

61
Q

Classification and symptoms of LUTS? (11)

A 
Storage / irritative (fun)
• frequency
• Urgency
• urge incontinence OAB
• nocturia
Voiding /obstructive (wisd)
• Weak stream (stranguria)
• intermittency
• straining or hesitancy; spraying/splitting
• Dysuria (discomfort)
• dribbling terminal (due to stranguria)

Post-voiding
• incomplete emptying
• post-micturition dribble

62
Q

What should be excluded if enuresis? (2)

A

Vesico-ureteric reflux with indirect cystogram and ultrasound
Neuropathic bladder with ultrasound, mcug, uds

Urology (18 decks)

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