Y3 Surgery > 9 - KUB > Flashcards

9 - KUB Flashcards

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1
Q

What is the aetiology of LUTS in men and women?

A

Most common:

Men: BPE (BPH)

Women: UTI

Drinking fluids late at night, excess alcohol intake, and excess caffeine intake can exacerbate LUTS. Polyuria caused by T2DM can mimic LUTS

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2
Q

How can LUTS be categorised?

A
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3
Q

What are some important questions/examinations to do when a patient presents with LUTS?

A

- Associated symptoms: visible haematuria, suprapubic discomfort, or colicky pain

- DHx: anticholinergics, antihistamines, bronchodilators are known to exacerbate LUTS

- Consider DRE and examination of external genitalia

- IPSS score

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4
Q

What are some investigations done when patients present with LUTS?

A

Initial

  • Urinalysis and culture
  • Urinary frequency and volume chart
  • Post-bladder scanning and flow rate
  • Bloods (FBC, U+E’s, PSA)

Specialist

  • Gold standard is Cystoscopy and used if recurrent infection or haematuria

- Urodynamic studies to look at flow rate, detrusor pressure

  • Upper urinary tract imaging, such as via ultrasound or CT scanning
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5
Q

How are people with LUTS managed conservatively and pharmacologically, apart from treating the underlying cause?

A

Conservatively

  • Regulate fluid intake, alcohol and caffeine
  • Urethral milking and double voiding
  • Pelvic floor exercises
  • Bladder training techniques

Pharmacologically

  • Alpha blockers
  • B3 agonists
  • Anticholinergics
  • Loop diuretics
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6
Q

What are some complications of leaving LUTS untreated?

A
  • Risk of infection
  • Renal and bladder calculi due to stagnation
  • Overflow incontinence if chronic obstruction
  • Renal failure
  • Bilateral hydronephrosis
  • Acute renal failure with BPH
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7
Q

How can haematuria be classified and what is the aetiology?

A

- Visible (VH) OR

- Non visible (a-NVH/s-NVH): symptomatic or asymptomatic OR

- Pseudohaematuria: foods like beetroot, medication (such as rifampicin or methyldopa), hyperbilirubinuria, myoglobinuria

  • BPH can also cause haematuria
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8
Q

What questions do you need to ask in a history with someone presenting with haematuria?

A
    • Timing:* if total suggests bladder or upper tract source, if terminal then severe bladder irritation
    • Recent trauma*
    • DHx*
    • Smoking status* (urological cancer)
    • Exposure to industrial dyes* (bladder cancer)
    • Travel history* (Schistosomiasis)

Abdominal exam, possible DRE and possible genital exam

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9
Q

How are patients with haematuria investigated?

A

Initial

  • Urinalysis (check for nitrates/leucocytes to indicate infection. Trace blood not haematuria, needs to be >1+)
  • Baseline bloods (FBC, U+E’s, Clotting)
  • PSA after counselling
  • If deranged renal function take ACR
  • Refer to specialists

Specialist Ix

  • Flexible cystoscopy is gold standard
  • Urine cytology
  • US KUB imaging for NVH
  • CT Urogram for VH
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10
Q

What is acute urinary retention and the aetiology of this?

A

New onset inability to pass urine which leads to pain and discomfort with significant residual volumes

Most common cause: BPH

Obstructive causes: urethral stricture, prostate cancer, constipation, UTIs

Medication: antimuscarinics, spinal anaesthesia

Neurological: severe pain, peripheral neuropathy, iatrogenic nerve damage during pelvic surgery, UMN disease (MS, Parkinson’), Bladder Sphincter Dysinergy

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11
Q

What are the clinical features of acute urinary retention?

A
  • Acute suprapubic pain
  • Inability to micturate
  • Palpable distended bladder with tenderness
  • Acute confusion in the elderly

Do PR to rule out constipation and prostate pathology

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12
Q

What are some investigations that are done when acute urinary retention is suspected?

A

- PR/PV exam

-Post-void bedside bladder scan

- Post catheterisation CSU/MSU

- Routine bloods (FBC, U+E’s, CRP)

- US KUB scan if suspect high pressure retention to look for hydronephrosis

- Monitor for post-obstructive diuresis

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13
Q

How is acute urinary retention managed?

A

- Immediate catheterisation and measure residual volume

- Treat underlying cause e.g Tamsulosin for BPH

  • Check CSU for infection and review meds to see if there was a cause

- If large retention volume (>1000ml) monitor for post-obstructive diuresis

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14
Q

How long should a catheter be left in place after an episode of acute urinary retention and what complications would occur if they had not been treated with catheterisation?

A

- High-pressure urinary retention: keep in place until definitive treatment (e.g TURP) to prevent further rentions that could cause an AKI and eventually CKD

- No evidence of renal impairment: TWOC 24-48 hours after insertion. If unsuccessful try again in TWOC clinic after longer interval. If mutiple failed attempts long term catheter until definitive treatment

Complication: AKI, CKD, renal scarring, UTI, renal stones due to stasis

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15
Q

What is the pathophysiology of chronic urinary retention?

A

Most common in men: BPH

Most common in women: pelvic prolapse (such as cystocele, rectocele, or uterine prolapse)

Other: urethral strictures, prostate cancer, pelvic masses (fibroids), peripheral neuropathies, UMN diseases (MS)

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16
Q

How does chronic urinary retention present?

A
  • Painless urinary retention
  • Palpable distended bladder that is NOT tender
  • Voiding LUTS e.g hesitancy, weak stream
  • Overflow incontinence
  • Nocturnal enurisis

Do DRE to check for prostate enlargement

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17
Q

How is chronic urinary retention investigated and managed?

A

Ix

  • Post-void bedside bladder scan to look at retained urine
  • Routine bloods (FBC, U+E’s, CRP)
  • US KUB if high-pressure retention to look for hydronephrosis

Mx

  • Treat underlying cause, catheterise if >1000ml residual whilst waiting for treatment
  • Long term catheter/ICS with monitoring for post obstructive diuresis
  • NO TWOC as concerns of repeat renal injury
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18
Q

What are the complications of chronic urinary retention?

A
  • UTI
  • Bladder calculi
  • CKD if repeated episodes
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19
Q

What are the different compositions of renal tract stones (kidney and ureter stones)?

A

More common in males <65

- Calcium (80%): calcium oxalate (35%), calcium phosphate (10%), or mixed oxalate and phosphate (35%)

- Struvite: magnesium ammonium phosphate, cause staghorns

- Urate: only radiolucent stones

- Cystine

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20
Q

What is the pathophysiology of renal tract stones?

A

Oversaturation in the urine

Cystine: homocystinuria affects the absorption and transport of cystine in the bowel and kidneys so builds up

Urate: high levels of purine in the blood, from diet (e.g. red meats) or through haematological disorders (such as myeloproliferative disease)

Hypocitraturia: citrate is a stone inhibitor so less of it causes stoens to form

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21
Q

What are the clinical features of renal calculi and what are some differential diagnoses?

A
  • Sudden onset one sided severe pain radiating from flank to pelvis (loin to groin ureteric colic) due to increased peristalsis around obstruction
  • N+V
  • Haematuria (usually non-visible)
  • May have fever, rigors or lethargy if associated with infection (CONSIDER SEPSIS)
  • Exam usually remarkable, may be some flank/renal angle tenderness but no suprapubic tenderness

DD: pyelonephritis, ruptured AAA, biliary pathology, bowel obstructon, MSK pain, lower lobe pneumonia

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22
Q

How are suspected renal calculi investigated?

A
  • Urine dip and culture (microscopic haematuria)
  • Routine bloods (FBC, CRP, U+Es, Urate, Ca)

- Gold standard imaging: Non-contrast CT KUB

- Other imaging: AXR with IV urogram (most stones not radiolucent and high radiation exposure) or US to assess for hydronephrosis

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23
Q

How are renal calculi managed initially after diagnosis on investigation before definitive management?

A

Initial

  • IV fluid resus as lot of vomiting and reduced fluid intake

- Sufficient analgesia (opioids or PR NSAIDs)

  • IV abx and urology referral if suspect sepsis
  • JJ stent or Nephrostomy immediately if obstructive nephropathy causing renal damage (infection and obstruction)
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24
Q

How are renal calculi managed definitively if they are over 5mm so cannot be passed spontaneously with hydration and analgesia?

A

Extracorporeal Shock Wave Lithotripsy (ESWL): sonic waves break up then pass spontaneously. Used for small stones and radiological guidance. Contraindicated in pregnancy or a stone over a bony landmark e.g pelvis

Percutaneous nephrolithotomy (PCNL): large and staghorn calculi. Percutaneous access then nephroscope put into renal pelvis and stones fragmented by lithotripsy

Flexible uretero-renoscopy (URS): passing a scope retrograde up into the ureter, fragmented through laser lithotripsy and the fragments subsequently removed

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25
What are some complications of recurrent kidney stones and how can we prevent stones from recurring?
- Infection - AKI - Renal scarring and loss of kidney function with repeated stones
26
What is the aetiology of bladder stones, how do they present and what issues arise if they are not treated?
- Urinary stasis from **chronic urinary retention** or secondary to **schistosomiasis** or as **passed ureteric stones** - Present with LUTS - Treated by **cystoscopy** allowing them to drain or lithotripsy - Chronic irritation if left can cause **SCC of the bladder**
27
Where do kidney stones get lodged?
1. VUJ 2. Pelvic brim 3. PUJ
28
What questions do you need to ask yourself when there is a renal calculi presentation?
- Composition? - Why have they got this stone now? - Any predisposing factors? - Any anatomical abnormalities? - Any family history? - Any infection above the stone?
29
What is the pathophysiology of pyelonephritis?
**Inflammation** of the **kidney parenchyma** and the **renal pelvis.** Uncomplicated if non-immunocompromised and normal anatomy, complicated otherwise From **bacteria** either **ascending the lower urinary tract,** from the **blood stream** (infective endocarditis or septicaemia) or rarely from **lymphatics** from retroperitoneal abscess **Neutrophils infiltrate tubules** and interstitium and cause **supparative inflammation** (streaks of pus and renal cortical abscesses)
30
What organisms cause pyelonephritis?
**Most common:** E.Coli **Others:** Klebsiella, Proteus, Enterococcus faecalis (catheters), Staphylococcus aureus (catheters), Staphylococcus saprophyticus (commensal), and Pseudomonas (catheters) **Immunocompromised:** mycobacterium, yeast, fungi
31
What are some risk factors for developing pyelonephritis?
**- Factors reducing antegrade flow of urine:** e.g BPH, spinal cord injury **- Factors promoting retrograde ascent of bacteria:** female short urethra, indwelling catheters and JJ stents, VUR **- Factors predisposing to infection or immunocompromise:** DM, untreated HIV, corticosteroids **- Factors causing colonisation:** renal calculi, menopause (less oestrogen), sexual intercourse
32
What are the presenting features of pyelonephritis and what are some differential diagnoses you should consider?
**- Triad:** fever, N+V, unliateral loin to groin pain developing over 24-48h **- LUTS:** frequency, dysuria, urgency, haematuria - Costovertebral angle tenderness with/without suprapubic tenderness (consider AAA back pain) **- DD:** ruptured AAA, renal calculi, acute cholecystitis, ectopic pregnancy, PID, diverticulitis, lower lobe pneumonia
33
What are some investigations you should carry out if you suspect pyelonephritis?
- **Urinalysis** (nitrates, leucocytes, b-HCG) - **Urine culture** before starting abx - **Renal US** to see if obstruction as obstruction+infection is surgical emergency - **Non-contrast CT KUB** if obstruction suspected
34
How should you manage pyelonephritis?
- A to E **- Trimethoprim or Co-amoxiclav** IV abx **- IV fluids,** analgesia, antiemetics **- Admit if clinically unstable**, significant dehydration, or with co-morbidities such as diabetes mellitus, renal transplant graft, immunocompromised - Consider either **US or CT KUB** and **flexible cystoscopy** for males with no risk factors/not responding to abx to check for **pyonephrosis** and **perinephric abscess** that need draining
35
What are some of the complications of pyelonephritis?
- Severe sepsis - Renal scarring leading to CKD - Premature labour - Pyonephrosis - Chronic Pyelonephritis - Emphysematous Pyelonephritis
36
What is chronic and emphysematous pyelonephritis?
**_Chronic:_** ## Footnote **- Fibrosis** and destruction of the kidney due to repeated events of pyelonephritis - More common in obstructed systems resulting in **urinary reflux**, such as strictures caused by UTIs, VUR **- Small, scarred shrunken kidney** - More common in children, asymptomatic, **reverse any underlying cause** and consider **prophylactic abx** **_Emphysematous:_** - Caused by gas forming bacteria and has high mortality - **Presents like pyelonephritis but doesn't respond to abx** - **CT imaging** will show **gas** within and around kidney - Most common in diabetics as high glucose converted to CO2 by enterobacteria - If mild **broad-spectrum anti-microbial cover** - If severe **nephrostomy insertion** or **percutaneous drainage** and possible nephrectomy
37
Renal cell carcinoma is the most prevalent adult renal (not urinary tract) tumour. What is the pathophysiology of this?
- Mostly in developed countries between 50-70 years - **Adenocarcinoma** of the renal cortex usually in **PCT** and in the **upper pole of the kidney** - Can spread by **direct invasion** of perinephric tissues, adrenal gland, renal vein (tumour thrombosis) IVC; via **lymphatics** to pre-aortic and hilar nodes; or **blood** to the bones, liver, brain and lung.
38
What other carcinomas of the KUB system are there apart from RCC?
- Transition cell carcinoma (urothelial) - Nephroblastic carcinoma (Wilm's) - SCC of the bladder (schistosomiasis chronic inflammation)
39
What is the aetiology of RCC?
- **Most common:** smoking - Industrial exposure to carcinogens (cadmium, lead, aromatic hydrocarbons) - Dialysis - HTN - Obesity - Anatomical abnormalities (horseshoe, PCKD) - Genetic disorders (BAP1, Birt-Hogg-Dube syndrome)
40
How does RCC present?
**_Triad:_** - **Haematuria** (V or NV) **- Flank pain** **- Flank mass** - Vague symptoms like weight loss - Left sided by have left varicocele as tumour compresses testicular vein - Polycythaemia from EPO secretion - HTN
41
How is suspected RCC investigated?
**- Routine bloods** (FBC, U+E's, Ca, LFTs, CRP) - **Urinalysis** or **non-visible haematuria** and **cytology** - Initially **US KUB** **_- Gold standard:_** abdomen-pelvis pre and post IV contrast CT with additional chest CT for staging **- Biopsy**
42
How is RCC managed?
**_Localised_** ## Footnote - If small **partial nephrectomy** - If large **radical nephrectomy** to remove kidney (not adrenal gland), perinephric fat, local lymph nodes - If not suitable for surgery **percutaneous radiofrequency ablation** or p**ercutaneous cryotherapy** with renal artery embolisation before - If small slow growing and little life expectancy left anyway then can just **monitor** **_Metastatic_** - **Nephrectomy combined with immunotherapy (IF-a/IL2)** as chemo not suitable - **Biological agents** like Sunitinib/Pazopanib (Tyrosine Kinase inhibitors) - **Metastasectomy** (surgical resection of solitary metastases)
43
What is the prognosis with RCC?
- 25% have metastasis at presentation - 60% 5 year survival if have nephrectomy
44
What are the differences between simple and complex renal cysts?
Fluid filled sacs: **_Simple:_** Well defined outline and homogenous features. Made from renal tubule epithelium in response to previous ischaemia **_Complex:_** thick walls, septations, calcification, or heterogeneous enhancement on imaging. Classified with Bosniak classification and have risk of malignancy
45
What are some risk factors for developing renal cysts?
- Increasing age - Smoking - HTN - Male - Genetic conditions (ADPKD, tuberous sclerosis, and Von Hippel-Lindau disease) CONSIDER RCC AS A DIFFERENTIAL
46
How are renal cysts investigated?
- **CT or MRI imaging,** with **pre- and post-enhancement** scans with **IV contrast.** Use **Bosniak scoring system t**o stage after CT **- US** picks it up incidentally - **Check U+E's** for renal function and monitor this regularly if have genetic disease that predisposes to cysts
47
How are renal cysts managed and what is their prognosis?
**- Asymptomatic:** no follow up or treatment **- Symptomatic simple:** simple analgesia or needle aspiration with laparoscopic cyst deroofing to prevent recurrence **- Complex:** Depends on Bosniak stage ranging from surveillance to nephrectomy **- Complications:** infection, haemorrhage, rupture, progression to malignancy
48
What is the pathophysiology of the different types of urinary incontinence (involuntary leakage of urine)?
**_Stress_** ## Footnote - **Intra-abdominal pressure higher than urethral pressure** such as coughing, straining, laughing sneezing. - Weakness of pelvic floor seen post-partum, obesity, menopause, constipation, pelvic surgery (TURP) **_Urge_** - OAB (detrusor hyperactivity) leading to increased intra-vesicular pressure - Neurogenic, infection, malignancy and cholinesterase inhibitors can all cause **_Mixed_** - Combination of two **_Overflow_** - Chronic urinary retention as stretch of bladder wall damages efferent fibres of sacral reflex and loss of bladder sensation - BPH, spinal cord injury **_Continuous_** - Anatomical abnormality (such as ectopic ureter) or bladder fistulae (e.g. vesicovaginal fistula) or due to overflow
49
What are some investigations done when a present presents with urinary incontinence?
**- MSU dipstick** to check for infection and haematuria **- Post-void bladder scan** **- Urodynamic assessment** for UI if conservative management doesnt work **- Outflow urodynamics** - Others: cystoscopy, intravenous urogram, vaginal speculum examination, or MRI imaging
50
What are the different nerves and receptors involved in micturition?
**_Storage:_** Under sympathetic control by T10-L2 left and right hypogastric and S2-S4 somatic pudendal nerve under control of L centre in the pons **_Voiding:_** Under parasympathetic control S2-S4 pelvic splanchnic
51
What are the conservative and surgical management options for stress urinary incontinence?
**_Conservative_** ***- Lifestyle advice:*** less caffeine and alcohol, weight loss, smoking cessation, drinking less at end of day ***- Pelvic floor muscle training*** for at least 3/12 - If PFMT doesn't work offer ***duloxetine*** (serotonin-norepinephrine uptake inhibitor) **_Surgical_** ***- Tension-free vaginal tape*** - Open colposuspension (involving elevation of the bladder neck and urethra through a lower abdominal incision) - Intramural bulking agents - Artificial urinary sphincter
52
What are the conservative and surgical management options for urge urinary incontinence?
**_Conservative_** - Lifestyle advice (same as UI) ***- Bladder training*** for minimum of 6/52 ***- Antimuscarinics*** like oxybutynin/tolterodine **_Surgical_** ***- Botulinum toxin A injections*** - Percutaneous sacral nerve stimulation - Augmentation cystoplasty - Urinary diversion via ileal conduit.
53
What are the different histologies of bladder cancer and how can they be classified?
- Bladder cancer is most common urinary tract cancer. Most common in men and caught early so good prognosis **- TCC (90% of cases)**, SCC, Adenocarcinoma, Sarcoma
54
What are some of the risk factors for developing bladder cancer?
**- Most important:** smoking and increasing age - Aromatic hydrocarbons (industrial dyes and rubber) - Schistosomiasis (SCC) - Previous radiation to pelvis
55
How does bladder cancer present?
**- Painless haematuria** (either V or NV) **- Recurrent UTIs** or **LUTs** - Clinical exam usually remarkable - If metastatic may have systemic symptoms like weight loss and lethargy
56
What investigations are done when a bladder cancer is suspected?
**- Urgent flexible cystoscopy** under local anaesthetic - **Rigid cystoscopy** under general if suspicious lesion found on flexible - **Biopsy** on cystoscopy and consider **TURBT** **- CT staging** to look for muscle invasive and plan TURBT **- Urine cytology** (if cancer in cytology but not on cystoscopy then random biopsy on cystoscopy)
57
How is non-muscle-invasive bladder cancer managed?
**- Carcinoma in situ or T1:** TURBT **- Higher risk in situ:** adjuvant intravesical therapy, such as Bacille Calmette-Guerin (BCG slowing progression) or Mitomycin C as an outpatient. Stimulates type IV hypersensitvity to activate immune cells to tumour antigens **- High risk or limited response to above:** radical cystectomy **- Regular surveillance** by cytology/cystoscopy of all people as high recurrence rate and if recurs more invasive
58
How is muscle-invasive bladder cancer managed?
**- Radical cystectomy with neoadjuvant chemotherapy** with cisplatin combination **- Ileal conduit formation with urostomy** or **bladder resconstruction** from small bowel draining either urethral or catheter **- Regular follow-up with CT** to monitor for local and distant recurrence. Also check **B12 and folate** annually due to resection ileum
59
How is Locally Advanced or Metastatic Bladder Cancer managed?
**- Chemotherapy:** either cisplatin‑based regimen or a carboplatin plus gemcitabine-based regime - Any symptoms of the disease, such as pelvic pain, ongoing bleeding, or urinary frequency should be discussed at MDT **- Palliative options** should be discussed
60
What is the prognosis of bladder cancer?
- Patients who have had bladder cancer are at higher risk of developing upper urinary tract and urethral cancers - If superficial 5 year survival of 90%, if metastatic invasive 10-15%
61
What is removed in a radical cystectomy?
62
How can you tell the difference between renal calculi and peritonitis due to appendicitis and the difference between renal calculi and pyelonephritis?
Peritonitis patient will lay still but renal calculi patient will be rolling around in pain as calculi not irritating the peritoneum Pyelonephritis has LUTs but renal calculi will not unless calculi has reached VUJ
63
What is the triad of symptoms for renal cancer?
1. Flank pain 2. Flank mass 3. Haematuria Not often that all three at once
64
What are some important investigations to do if a patient presents to A+E with haematuria?
- Urine dipstick - Routine bloods inc U+Es and psa - DRE - Bladder scan and catheterise if retention - CT urogram
65
If a patient has a high PSA, raised ALP and enlarged prostate what is the likely diagnosis?
Prostate cancer with bone involvement!!!
66
When are three way catheters used?
To remove a blood clot in the bladder causing obstruction, one for balloon, one for irrigation, one for bag
67
What is the most common renal stone and how can they be managed conservatively?
**Calcium Oxalate** - Fluids - Analgesia - Alpha blockers (Tamsulosin)
68
How can you avoid renal calculi?
* Good hydration * Thiazides * Low protein and low salt diet
69
What are some urological emergencies?
* Haematuria * Chronic high pressure retention
70
What else can chronic high pressure retention present as and why is it important to pick up?
* Overflow incontinence overnight * Can lead to hypoK and cardiac arrhythmias so need admitting ASAP with catheter and monitoring for post-obstructive diuresis (hourly urine output, weight BD, U+Es BD)
71
What else can chronic high pressure retention present as and why is it important to pick up?
* Overflow incontinence overnight * Can lead to hypoK and cardiac arrhythmias so need admitting ASAP with catheter and monitoring for post-obstructive diuresis (hourly urine output, weight BD, U+Es BD)
72
What can the timing of haematuria tell us?
**Initial:** Urethral origin **Mixed:** Kidney origin **Terminal:** Bladder origin
73
If someone has clot haematuria what do you need to do?
* Three way catheter and irrigate * Even if due to anticlotting drugs need to investigate in haematuria one stop clinic
74
What investigations are done in the one stop haematuria clinic?
Need to check whole urinary tract **Visible:** CT urogram, Flexi cystoscopy, PSA, PR exam **Non-Visible:** US KUB, same as above
75
What gold standard imaging is used for renal stones and what is an easy way of almost ruling out renal stones?
**Non-contrast CT KUB** Check for haematuria on urinalysis, if none then unlikely
76
What are some unusual presentations of renal colic?
* Lower abdominal pain * Testicular pain (VUJ) * Labia pain (VUJ)
77
How can you tell if someone is in chronic HIGH PRESSURE retention and will need a catheter? (low pressure retention doesn't need catheter)
Check their U+Es, urinalysis and US for hydronephrosis!!!!!!!!
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