Phase 2 Kate McDonald and Rebecca Marlor

Phase 2

Kate McDonald and Rebecca Marlor

The Peer Teaching Society is not liable for false or misleading information…

• To understand the diagnosis, investigation and management of some common urological conditions


Aims

• Benign prostatic obstruction• Prostate Cancer• Urinary tract infections (UTIs)• Acute kidney injury (AKI)• Chronic kidney disease (CKD)


Introduction:

• Definitions:– BPH: Benign prostatic hyperplasia (histological)

– BPE: Benign prostatic enlargement (DRE)

– BPO: Benign prostatic obstruction


Benign Prostatic Hyperplasia

• Common in elderly men (60-70 years old)• Usually asymptomatic until late on

• Mechanism poorly understood

• Expansion of the central zone, effects both the glandular and connective tissue


Benign Prostatic Hyperplasia

Symptoms Signs

Storage symptoms

Frequency Smooth enlarged prostate on DRE, Palpable median sulcus

Urgency

Nocturia

Overflow incontinence

Voiding Terminal dribbling

Difficult initiation

Poor flow/straining

Hesitancy

Overflow incontinence

Inadequate emptying of bladder


Benign Prostatic Obstruction

Differential Diagnosis:-Prostate Cancer-Urinary bladder Cancer-Bladder stone-Urethral stricture-Prostatitis-Detrusor overactivity



Investigations:-? PSA-Symptom questionnaire (IPSS) -Urinalysis-U&Es (Creatinine), FBCs, LFTs



A man presents with LUTS and you think it is probable he has BPH, what investigations would

you want to arrange?

Management:•Conservative

– Watchful waiting

•Medical– Alpha adrenergic antagonists (Doxazosin/Tamsulosin)– 5-alpha reductase inhibitors (Finasteride)

•Surgical– TURP/prostatectomy



Causes:•Benign Prostatic Hyperplasia •Prostate cancer•Prostatitis•Neurological (disc rupture/metastasis)•Urethral pathology•Pelvic mass lesions/constipation•Anticholinergic drugs


Acute Urinary Retention!!

67 year old gentleman presents with 24/24 inability to pass urine (anuria) and 12/24 supra-pubic abdominal pain? You suspect he has acute

urinary retention?

What are the different causes?

• EMERGENCY!• Check for neurological

deficits!!• Don’t measure PSA• Catheterization• Urine output• ? Surgery


Acute Urinary Retention!!Symptoms Signs

SUDDEN Inability to pass urine

Bladder palpable and distended

Supra-pubic pain Tender supra-pubicly

Enlarged prostate

Agitation

Anal toneSaddle anesthesia

Upper and lower limb Power/reflexes/

• Incomplete bladder emptying

• Often asymptomatic, but can get LUTS + overflow incontinence, NOT painful!

• Acute on chronic retention• Hydronephrosis + bladder hypertrophy -> chronic renal failure


Chronic Urinary Retention!!

What serious complications do we worry about?

Investigations:Monitor U&Es and urinary proteinsUpper UT imaging

Management:Intermittent catheterisation? Surgery


Chronic Urinary Retention!!

• Most common male cancer• Hormonally driven - dihydrogentestosterone

• Adenocarcinoma, peripheral, ?multi-focal

• Localized• Locally advanced• Metastatic


Prostate Cancer:

Symptoms

? LUTS

Acute urinary retention

Back/perineal or testicular pain

Haematuria

Stress incontinence

? Constipation, leg swelling

Weight loss

Anorexia

Fatigue

?Bone pain + pathological fractures


Prostate Cancer

DRE:Asymmetrical nodular

enlargement of the prostate

“Hard and Craggy”

Loss of median sulcus

DRE:Asymmetrical nodular

enlargement of the prostate

“Hard and Craggy”

Loss of median sulcus

What would you expect to find on DRE?

Investigations:•PSA•TRUS +/- biopsy

•?MRI/CT scan•? Isototope bone scan

•Gleason Grading and Clinical Staging


Prostate Cancer:


Prostate Cancer


Prostate CancerManagement:Localised Prostate Cancer•Watch and wait•Active follow up•Radical prostatectomy•Radiotherapy (brachytherapy/external beam)•Focal therapy


Prostate CancerManagement:Locally advanced Prostate Cancer•Neoadjuvent hormonal therapy

– LHRH Agonists (Goserelin injections): hot flushes, lethargy, loss of sexual function

– Anti-Androgens: gynaecomastia, nipple tenderness, sometimes retain sexual function

•Radiotherapy


Prostate CancerManagement:Metastatic Prostate Cancer:•Hormonal therapies•Chemotherapy/radiotherapy to improve symptoms and disease control•Bisphosphonates

• “Acute Renal Failure”

• Abrupt onset (<48 hours) kidney impairment

• Sustained (>24 hours) reduction in GFR, UO or both


AKI

• Estimated Glomerular Filtration Rate– Based on serum creatinine, age, sex and race– Calculated using complicated mathematical

equation……Modification of Diet in Renal Disease (MDRD)

– “Normal” < 100 ml/min/1.73m2

– Independent risk factor for CVS disease


eGFR

• NICE: Kidney Disease: Improving Global Outcome score (KDIGO)

• Officially (any of) :– Rise in serum creatinine > 26µmol/L in 48 hours– >50% rise in serum creatinine within 7 days – Fall in UO (<0.5ml/kg/hr) for >6 hours (adults) or

>8 hours (paeds)– >25% fall in eGFR in children and young people

within 7 days The Peer Teaching Society is not liable for false or misleading information…

AKI Classification

Stage Serum Creatinine UO criteria

1 Increase > 26µmol/L within 48 hours or increase > 1.5-1.9X reference creatinine

<0.5mL/kg/hr for >6 hours

2 Increase > 2 -2.9 X reference creatinine <0.5mL/kg/hr for >12 hrs

3 Increase > 3X reference creatinine, increase >4mg/dl or started renal replacement therapy

<0.3mL/kg/hr >24 hrs or anuria for 12hrs


AKIN Classification


AKI Aetiology

PRE RENAL

POST RENAL

RENAL

A: Catheter blockedB: Congestive Heart FailureC: HaemorrhageD: GoodpasturesE: Renal calculiF: ACE inhibitor G: Acute Tubular NecrosisH: NSAIDsI: Renal Artery StenosisJ :BPH


Classify the following causes..

PRE RENAL, RENAL or POST RENAL???

Pre Renal Renal Post Renal

B D A

C G E

F H

H

I


Answers

• COMMONEST CAUSE OF AKI– Decreased intravascular volume

• Haemorrhage, shock, burns, D+V

– Decreased effective circ volume• CCF, cirrhosis

– Drugs• ACE, ARB, NSAIDs

– Renal artery stenosis


Pre renal

•Acute Tubular necrosis (ATN)–Secondary to hypoperfusion/toxin–Red cells/granular casts

•Tubular interstitial nephritis (antibiotics, NSAIDS)•Acute and chronic pyelonephritis•Glomerulonephritis *•Hepatorenal syndrome


Renal

• IgA nephropathy– Young male with recurrent haematuria after URTI

• Goodpastures– Anti-glomerular basement membrane disease– Haemoptysis and haematuria

• Proliferative GN– Post strep infection

• Minimal change– Common in paeds

• Rapidly progressive GN– ESRF in days


Glomerulonephritis

• Intraluminal– Calculus, clot, sloughed papilla

• Intramural– Ureteric malignancy, stricture, post raditaion

fibrosis, bladder ca, BPH

• Extrinsic– Retroperitoneal fibrosis, pelvic malignancy.


Post renal

• Urine– Dipstick: leuks, nitrites, blood, prot*, glucose

• * Albumin:creatinine to quantify– ?osmolality, ?culture

• Bloods– FBC, U+E, LFT, clotting, ESR/CRP– ?blood culture, ?ABG, ?Immunology

• ECG• Imaging

– US 1st line– CT

• ?Renal Biopsy


Investigation

• TREAT CAUSE• Assess fluid status…..is the patient dehydrated?

– Low UO, JVP, poor tissue turgor, low BP, high pulse

→ IV FLUIDS• Identify and relieve any obstruction. • Stop nephrotoxic drugs!• Dialysis if renal function does not recover


AKI Management

• 68 year old male gen unwell – fatigue, malaise, N+V, anorexia

• Started on ramipril for HTN• PMH: IHD• O/E Bilateral Renal BruitsDifferentials? What investigations?• Bloods- High urea and creatinine → AKI• Urine NAD


Case 1


Case 1HYPERKALAEMIA

• Tented T waves• Flattened P waves• Prolonged PR• Wide QRS Sine wave pattern, asystole

• IV Calcium (cardioprotective)– 10 ml of 10% Ca gluconate IV

• IV Insulin + glucose (increases intracellular uptake)

• Salbutamol nebuliser

Patient potassium stabilises What next?


Case 1

• Stop ramipril• Find and treat cause

– CT: bilateral renal stenosis, atheromatous changes

– Refer to vascular – stents which improves BP control


Case 1

• Kidney damage ≥ 3/12 based on findings of abnormal kidney structure or function

OR

• GFR<60mL/min/1.73m2 for >3/12 with or without evidence of kidney damage.


Chronic Renal Failure

Stage GFR (mL/min/1.73m2) Notes

1 >90 Normal GFR + evidence of renal damage

2 60-89 Slight decrease in GFR + evidence of renal damage

3A 45-59 Moderate decrease in GFR ±evidence of renal damage3B 30-44

4 15-29 Severe decrease in GFR ± evidence of renal damage

5 <15 Established renal failure


CKD Classification

Evidence of Renal Damage:•Persistent microalbuminuria•Persistent proteinuria•Persistent haematuria •Structural Abnormalities of the kidneys by USS eg ADPKD•Positive biopsy for chronic glomerulonephritis


CKD Classification

• Limitations:

– Validated for patients with established RF– Most elderly people are in Stage 3 by eGFR– eGFR very dependent on diet– Formula less accurate for higher eGFR


CKD Classification

Vascular HTN, Renovascular diseaseInfective/Inflamm GNTraumaAI SLE, PANMetabolic DMIatrogenic/Idiopathic Drugs, contrastNeoplastic Myeloma, Renal Ca, Prostate CaCongenital ADPKD, Fabrys, Alports


Aetiology


Clinical PresentationSymptoms •N/V, anorexia•Peripheral neurpathy High urea•Pruritus•Lethary•Confusion

•Sx of underlying cause–Urinary sx – dysuria, increased frequency, nocturia, terminal dribbling–SLE– rash, arthalgia, dry mouth, pleuritic chest pain

• Hx• PMH

• DM,IHD. • DH

• NSAIDs• FH

• ADPKD


Clinical PresentationO/E•HTN•Palpable kidneys•Palpable bladder•PR- enlarged prostate•Renal or femoral bruits•Rash•Peripheral Oedema•Pallor

• Blood– FBC, U+E, LFT, Lupus/vasculitis/myeloma screen

• Urine– MC+S, dipstick, ACR

• Imaging– USS– CXR, ECG – Renal biopsy: if cause unclear


Investigations

• Treat reversible causes– Obstruction?

• Avoid Nephrotoxins– NSAIDs, Gentamicin, Li, Contrast

• Treat complications• Dialysis/ Transplant


Management

Fl uid overloadA cidosisS x of uraemia (fatigue, anorexia, pruritus)H TNB one diseaseA naemiaC VS diseaseK Hyperkalaemia


Complications

• Manifestation of renal disease• Pathophysiology:

– Decreased activation of 1.25 vit D. – Lower Ca abs from gut– Increased PTH → 2O hyperPTH– Increased bone turnover – Rugger jersey spine


Renal Osteodystrophy

THINK is this ACUTE or CHRONIC?1.Hx – Cormordity = chronic2.Longstanding decrease in eGFR3.SIZE OF KIDNEYS – usually small in chronic (<9cm)4.Absence of anaemia, low calcium suggests acute


Assessing renal function…..

• Urethritis + Cystitis = symptoms of ‘UTI’

- Pathophysiology:alkaline urineurine osmolaritymicturation volume, commensals

- Majority Contamination with bowl flora (E-Coli)


Lower Urinary Tract Infection

Differential Diagnosis:-Urethritis (Chlamydia)-Urethral syndrome


Symptoms Signs

Frequency Haematuria (Microscopic/Macroscopic)

Dysuria Cloudy smelly urine

Suprapubic pain during and after voiding

Strangury

Features suggestive of pyelonephritis = fever, rigors, loin pain, N&V, guarding and

tenderness


Investigations:•Urine dip•MSU MC&SIf infection is complicated consider U&Es, FBCs and blood cultures



Management:-Increase fluid intake (>2Litres/day)

-Trimethoprim – 200mg PO BD (3/7)- Alternative Nitrofurantoin (in pregnancy) (PO)- Ciprofloxacin and co-amoxiclav (PO)



First line antibiotic for LUTI? What about in pregnancy?

• Loin pain, fever and tender renal angle• Nausea, vomitting, (Septic shock)

• Usually an ascending infection

• Complications: perinephric abscesses, papillary necrosis, ureteric obstruction, AKI,


Acute Pyelonephritis

Differential Diagnosis (Pyelonephritis):-Acute appendicitis-Diverticulitis-Cholecystitis-Ruptured ovarian cyst-Ectopic pregnancy



ALWAYS consider in

pre-menopausal women!!

Differential diagnosis of acute pyelonephritis?

Investigations:•Dipstick•MSU MC&S•Renal tract USS/CT•Pelvic examination (women)DRE (men)•Blood cultures (if pyrexial)



Investigations for patient with pyelonephritis?

Management:•? Hospital admission

•Co-amoxiclav/Ciprofloxacin (PO) OR Gentamycin + Cefuroxime (IV)

•Paracetamol•Maintain high fluid intake



First line oral antibiotic treatment?IV antibiotic treatment regime?

An 80 year-old man attends his General Practitioner complaining of passing urine very frequently. His symptoms started about 5 years ago and have gradually worsened, so that for the last 12 months he has been passing urine hourly but never felt like his bladder was properly empty. During the last 2 days, he noticed some blood in his urine and felt hot and sweaty. This prompted him to seek medical advice. His GP diagnoses a lower urinary tract infection.

1. From the patient’s history, what condition may have predisposed to the development of this infection? (2 marks)


MEQ

An 80 year-old man attends his General Practitioner complaining of passing urine very frequently. His symptoms started about 5 years ago and have gradually worsened, so that for the last 12 months he has been passing urine hourly but never felt like his bladder was properly empty. During the last 2 days, he noticed some blood in his urine and felt hot and sweaty. This prompted him to seek medical advice. His GP diagnoses a lower urinary tract infection.

CHRONIC URINARY RETENTION


MEQ

2. List 4 other symptoms you might enquire about in relation to the patients chronic urinary problems (2 marks)

LUTS – NocturiaHesistancyTerminal dribbling

Poor urinary stream Intermittent stream Urgency


MEQ

3. List 2 physical signs that you may expect to elicit on abdominal/PR exam (2 marks)

• Palpable bladder• Enlarged prostate• Palpable kidney


MEQ

4. The patient is referred to a urologist for definitive treatment. In the meantime, a midstream specimen of urine is sent for culture. The results of a gram stain show a gram negative bacillus. List 2 possible pathogens that may be responsible for the patient’s infection. (2 marks; 1 mark per response)

• Escherichia coli (E. coli)• Enterobacter• Klebsiella sp.• Pseudomonas aeruginosa• Serratia sp.


MEQ

5. The urologist recommends that the patient undergo an operation to relieve his chronic urinary symptoms. What operation is he most likely to have suggested? (2 marks)

TURP (Transurethral resection of prostate)


MEQ

A 61-year-old man presents to his General Practitioner complaining of increasing difficulty in passing urine. On rectal examination the GP feels an enlarged hard, irregular prostate gland and suspects the diagnosis of carcinoma of the prostate. The patient is referred to the Urology department at the local hospital.State two tests that will aid confirmation of the diagnosis (2)

Transrectal USSProstatic biopsyProstate Specific Antigen


MEQ 2

The results of these tests confirm prostate cancer. Give two investigations, which will assist in assessing the extent of the disease (2)

Transrectal USSCT scan of abdomen (and chest)Alk phosphataseSerum CalciumIsotope bone scanPlain radiographs of axial skeleton


MEQ 2

State 3 treatments that may be used in this condition (3)

Prostate surgeryRadiotherapyAnti-androgen therapyOrchiectomy


MEQ 2

Treatment is conducted and the GP manages his subsequent follow up care. Three months later the patient becomes increasingly unwell. He complains increased thirst and has also noticed increased urinary frequency. He has become markedly constipated and his wife says that he is has become far less mentally sharp than he had been previously. The GP arranges admission to hospital.What is the most likely cause of these new symptoms? (1)

HYPERCALCAEMIA (?bony mets)


MEQ…Bonus question!

• a. Amoxicillin f. Flucoxacillin• b. Antibiotic treatment is not indicated g. Gentamicin• c. Ceftazidime h. Nitrofurantoin• d. Cephalexin i. Trimethoprim• e. Ciprofloxacin j. Vancomycin

A 23-year-old woman presents to her GP with a 2-day history of urinary frequency and dysuria. Her last menstrual period was six weeks previously. She reports that she experienced facial swelling and wheezing when she was given either penicillins or cephalosporins as a teenager. Microscopy of her urine shows numerous white and red blood cells. Culture yields >105 /ml of a fully sensitive Escherichia coli.

HThe Peer Teaching Society is not liable for false or misleading information…

EMQ


A 60-year-old man is admitted with a fever. He has had repeated hospital admissions over the preceding year for an unrelated condition, and is known to carry MRSA in his nose. On taking a history, he describes recent onset urinary frequency, nocturia and loin pain. An MSU is sent to the laboratory. Microscopy shows numerous white blood cells and a culture yields >105 /ml of Staphylococcus aureus. This morning he has become hypotensive and confused.

J

• The Peer Teaching Society is not liable for false or misleading information…

EMQ


On admission to a residential home, a urine sample is sent from a 75-year-old man with a long-standing indwelling urinary catheter, because it looks cloudy and contains protein on dipstick. The patient is otherwise well. The culture yields >105 /ml of a Pseudomonas aeruginosa sensitive to standard antipseudomonal antibiotics.

BThe Peer Teaching Society is not liable for false or misleading information…

EMQ

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Phase 2 Kate McDonald and Rebecca Marlor

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