Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
33 Cards in this Set
- Front
- Back
- 3rd side (hint)
4 main types of renal calculi?
Whiche are radio-opaque? |
1) Oxalate stones (60%) / Spur / Dark brown/black / Radio-opaque
2) Phosphate stones (Ca, NH3, Mg) (33%) / Staghorn / Chalky / Radio-opaque 3) Uric acid stones (95%) / Radiolucent 4)Cystine stones (1%) |
|
|
Clinical features of urinary stones?
|
1) Pain (loin > groin > testicular)
2) Infection (cystitis=freq,dysuria; Pyelonephritis=fever, N&V) 3) Haematuria 4) Pyuria 5) Oliguria, anuria 6) Renal impairment |
|
|
Renal colic - Hx
|
Diet: protein, sodium calcium, oxalate, purines, vitD
Fluid intake: Dehydrated? Exclude bowel disease, diarrhoea (dehydration) & use of antacids (calcium) Predisposing illness: UTI, HyperPTH, gout, hydronephrosis FHx Red flags: obstructive Sx for >2/52, obstruction+UTI, CRF |
|
|
Urinary tract calculi - Aetiology
|
1) Inadequate drainage (Et. calculi)
2) Excess of normal constituents in urine (eg. []'d urine, Ca++, urate, oxalate) 3) Lack of inhibitors of stone formation (eg. low citrate, Mg++) 4) Presence of abnormal constituents in urine (eg. hydronephrosis --> epithelial slough, foreign bodies) |
|
|
Renal colic - Immediate Mx
|
Analgesia (NSAID?)
IV Fluids Antibiotics (cefuroxime) Observation |
|
|
Renal Colic - Examination
|
Pain, Loin tenderness, restlessness
Diaphoresis Febrile, rigors (infection) |
|
|
Renal Colic - Ix
|
URINE:
Urinalysis: RBC, WBC, protein, glucose, pH (<5.5=urate stone; >8=infectious stone) M/C/S BLOODS: FBC U&E = renal function (eGFR) RADIOLOGY: Plain KUB (kidney/ureter/bladder) CT urography IVP pyelogram |
|
|
Renal Colic - Absolute indications for surgery?
|
Infection
Obstruction of a solitary kidney Impaction (of stones) Colic unresponsive to medication |
|
|
Renal Colic - Definition
|
= Renal Calculi?
Sharp, severe pain in the lower back over the kidney, radiating forward into the groin. Renal colic usually accompanies forcible dilation of a ureter, followed by spasm as a stone is lodged or passed through it. See also urinary calculus. |
|
|
Renal calculi - Lodgment Locations
|
1) Pelvi-ureteric junction (PUJ; renal pelvis
2) Ureter @ pelvic brim 2) Vesico-ureteric junction (VUJ) 3) Bladder-urethra |
|
|
Renal Colic - Mx options
|
1) Conservative (analgesia+fluids) - <5 mm (90%) pass spont.
2) ESWL (Extra corporeal shock wave lithotripsy) - stones <2cm; complic=bleeding, sepsis, fragments stuck 3) Percutaneous Nephrolithotomy (PCNL): >2cm; Complic=renal loss, sepsis, bleeding, colonic perf, air emboli 4) Ureteric stent 5) Ureteroscopic removal: Laser + basket removel 6) Open surgery - (uretero/pyelolithotomy rarely used for large stones) |
(5 s)
1) Symptomatic (conservative) 2) Sound (ESWL) 3) Skin (PCNL) 4) Stent (Ureteric stent) 5) Scope, slice, scavenge (Laser + basket) 6) Surgery (open uretero/nephrolithotomy) |
|
Complications of Renal Calculi
|
1) Hydronephrosis, ureteronephrosis (obstruction @ PUJ, pelvic prim, VUJ)
2) Infection: pyelonephritis, pyonephrosis (Mucosal injury & obstruction) 3) Anuria (impaction of calculi in ureter(s)) * solitary kidney 4) Malignant change to SCC(Chronic irritation) 5) Renal colic (impaction in ureter) |
1) Hydronephrosis, hydroureter
2) Anuria 3) Infection 4) Malignant change (SCC) 5) Renal colic |
|
UTI - Predisposing factors
|
Sex (female)
Sexual intercourse Pregnancy Stasis (structural, functional, FB) Vesicoureteral reflux Immunosuppression DM |
Sex (female)
Sexual intercourse Stasis (structural, functional, FB) Structural: BPH, urethral stricture, diverticula, pregnancy, congenital duplex system Functional: neruogenic bladder, spinal bifida, pregnancy Foreign body: Calculi, urinary catheter, instrumentation Vesicoureteral reflux Immunosuppression DM |
|
UTI - Factors in post-menopausal women
|
Vaginal atrophy - vaginitis
Oestrogen deficiency ++ Residual urine volume Need longer course of ABs |
|
|
UTI - Pathogenesis
|
1) Ascending infection
2) Hematogneous spread (debilitated, immunocompromised) |
1) Ascending infection: Urethra > Bladder > Ureter (via VUR) > Renal pelvis > Renal parenchyma (via intrafenal reflux)
2) Hematogneous spread (debilitated, immunocompromised) |
|
UTI - Microbiological causes
|
- Mostly from intestinal flora
- Community acquired (KEEPS): Klebsiella pneumoniae Escherichia coli (70-80%) Enterobacter Proteus mirabilis Staphylococcus saprophyticus (15%) Candida albicans Trichomonas vaginalis (protozoa) - Hospital acquired: Above + Pseudomonas aeruginosa |
|
|
UTI - Upper vs Lower Symptoms
|
Lower UTI - dysuria, frequency
Upper UTI - loin pain, fever |
Lower UTI
Dysuria (burning/stinging) Frequency, urgency, nocturia Suprapublic pain - feeling of incomplete emptying Cloudy, smelly urine +/- hematuria Upper UTI Loin pain; may radiate to iliac fossa & suprapubic area Fever, rigors, malaise Vomiting Lower UTI symptoms |
|
UTI - Ix
|
MSU - MCS
Bloods Radiology |
MSU - MCS
Nitrates+, leukocyte esterase +/- blood & proteins culture usually + Bloods FBC: neutrophilia U&E: raised creatinine (2o to dehydration) Blood culture: exclude bacteremia Radiology: - req'd for all UTI in males & recurrent UTI in females - Renal USS - CT +/- contrast - MCU - for VUR - IVP - Ix obstruction |
|
UTI - Lower UTI Mx
|
1) Advice / prevention
(fluids, micturition, intercourse, wiping, cranberry juice) 2) Treat infection - Trimethoprim (=3): 300mg / od / 3d - Cephalexin = 500mg / bd / 5d - Amoxacillin+clavulanate = 500mg+125mg / bd/ 5d - Men = 14d - Post menopausal = 10d + prophylactic ABs 3) Find/treat underlying cause - Post-menopausal? HRT |
|
|
Pyelonephritis - Definition
|
inflammation of the kidney and its pelvis caused by bacterial infection
|
|
|
Pyelonephritis - Mx
|
- 7-14d therapy
- Serial urine cultures (wk 0,1,3) 1) Antibiotics 1) Mild-moderate infection: 10d, Cephalexin, Amoxiclav, thremthoprim 2) Severe infection (sepsis/vomting) - IV AB; Ampicillin+gentamicin (4-6g/kg/d) 2) Rehydration 3) Drain pyonephrosis / renal cabuncles 4) Remove obstructions |
|
|
Haematuria in a 47M - Causes
|
By anatomical location:
1) Kidney 2) Ureter 3) Bladder 4) Prostate 5) Urethra 6) Systemic 7) Other |
1) Kidney - Calculus, RCC, TCC, Glomerular nephritis(IgAN), trauma, pyelonephritis, PCOS, trauma, TB, embolism, infact, renal vein thrombosis
2) Ureter - Calculi, TCC 3) Bladder - Cystitis, calculi, TCC, trauma 4) Prostate - Carcinoma, trauma, BPH, prostatitis 5) Urethra - Trauma, stone, urethritis, neoplasm 6) Systemic - Bleeding diathesis 7) Other - Malaria, rhabdomyolysis, DM, SLE, vasculitis, amyloidosis |
|
Haematuria in a 47M - What would you ask the patient?
|
1) Onset & duration?
2) Color of urine? 3) Clots? 4) Pain? (**Painless = TCC unless proven otherwise) 5) What part of stream does haematuria occur? 6) Fever? 7) Symptoms of prostatism? 8) Bleeding disorders? Drugs? |
1) Onset & duration?
Transient/persistent, acute/chronic 2) Color of urine? Upper tract blood = well mixed, dark/blood-colored 3) Clots? Renal origin = fusiform Bladder origin = large clots 4) Pain? (**Painless = TCC unless proven otherwise) Loin = kidney Loin to groin = ureters (PUJ, PB, VUJ) Frequency, urgency, dysruia, suprapubic pain = cystitis Perieum = prostatitis 5) What part of stream does haematuria occur? Between voidings = urethra Initial = urethra, prostate Pan-micturation = upper UT, bladder Terminal = bladder neck, urethra, prostate 6) Fever? Suggests pyelonephritis 7) Symptoms of prostatism? Difficulty starting, poor stream, nocturia 8) Bleeding disorders? Drugs? Instrumentation - catheter, cystoscope |
|
Haematuria in a 47M - What would you look for in O/E?
|
General signs: Pyrexia, bruising/purpura, HTN/oedema, anaemia
Abdominal Signs: Bladder, kidney, DRE (PR), PV |
General signs:
Pyrexia - UTI / GN (post IgAN) Bruising/purpura - bleeding diathesis HTN, oedema - GN Signs of anaemia - weight loss, CRF (hemopoeitin) Abdominal Signs: Bladder - Urinary retention, tumour mass Kidneys - PCKD, hydronephrosis DRE(PR) - Prostate; tenderness=prostatitis, smooth+enlarged=BPH, Hard+rough=Ca PV - pelvic mass |
|
Haematuria in a 47M - Ix
|
Urine
Urine dipstick MCS Cytology Bloods FBC,ESR ELFT Clotting Radiology IVP, KUB USS CT+c Cytoscopy +/- ureteroscopy |
|
|
Acute Scrotal Pain - Hx
|
1) Sudden onset?
2) Gradual onset? 3) UTI or STD symptoms? 4) Trauma? 5) Dull,poorly localized ache? 6) PMHx of inguinal hernia w/ sudden onset of colicky abdo pain |
1) Sudden onset? (Testicular torsion)
2) Gradual onset? (Epididymo-orchitis) 3) UTI or STD symptoms? (Epididymo-orchitis) 4) Trauma? (Haematocele) 5) Dull,poorly localized ache? (Varicocele) 6) PMHx of inguinal hernia w/ sudden onset of colicky abdo pain (Strangulated hernia) |
|
Causes of acute scrotal pain
|
Torsion - testicular
Torsion - appendage Epididymo-orchitis Trauma & haematocele Tumour - testicular Strangulated hernia Varicocele Scrotal skin: dermatitis, infected sebacious cyst, HSV, Behcet's disease Referred pain: Renal colic, T10, ilioinguinal N entrapment, cord neuralgia |
Behcet's Disease:
Autoimmune vasculitis |
|
Acute Scrotal Pain
Degree of urgency if torsion is suspected? |
Surgical exploration mandatory within 6h
Beyond 6h, testicle becomes non-viable |
|
|
Acute Scrotal Pain - Non Urgent Ix
|
WCC/ESR
USS for testicular blood flow MSU for UTI (epididymo-orchitis) |
|
|
Scrotal Lump - Causes
Unable to get above? |
1) Indirect inguinal-scrotal hernia
2) Varicocele 3) Scrotal (infantile/communicating) hydrocele of the spermatic cord |
|
|
Scrotal Lump - Causes
Can get above? |
1) Spermatocele
2) Hydrocele 3) Haematocele 4) Sebacious cyst |
|
|
Scrotal Lump - Causes
Solid masses? |
Testicle:
1) Tumour 2) Torsion 3) Orchitis 4) Gumma, TB Epididymis: 5) Epididymitis 6) Hydatid of Morgagni |
|
|
Scrotal Lump - Examination
|
Look:
Supine and standing Transillumination Feel: Get above? Cough impulse? Reducible? Part of testis? Solid or cystic? Tender? Move: Fluctuance Other: Weight loss Lymphadenopathy Hepatomegaly Pleural effusions |
|