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33 Cards in this Set

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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