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Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

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Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan
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Page 1: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Urology Case

Aningalan, ArvinAntonio, AbigaileAramburo, Jan

Page 2: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Case 1

• A 45 y/o ,male company executive presented in the emergency room with a 2 day episode of right flank pain and gross total hematuria.

Page 3: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

History of Present Illness

• He experienced dull aching pain radiating to the right testicle but was able to work, sleep, and generally experience no disability.

2-3 weeks PTA

Page 4: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Physical Examination

• Vital signs were stable. • HEENT, heart and lungs were normal. • Abdominal findings:

– (+) right CVA tenderness – absence of peritoneal irritation– bowel sounds were normal – no palpable masses

• Genitalia and rectal examinations were essentially normal.

Page 5: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Laboratory findings

Urinalysis:• 20-30 RBC/hpf • WBC 2-4hpf = normal

Page 6: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Salient features

• Male• 45 years old• right flank pain • gross total hematuria• dull aching pain for the past 2-3

weeks radiating to the right testicle• (+) right CVA tenderness

Page 7: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Clinical Impression

• Upper urinary tract obstruction (kidney,ureter) – It is characterised by pain in the flank,

often radiating to either the abdomen or the groin.

– (+) CVA tenderness– Total hematuria

• has its source at or above the level of the bladder (eg,stone, tumor, tuberculosis, nephritis).

Page 8: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Guide questions

• How would you explain the testicular pain?

• Differentiate the two types of pain which originates from the GU system.

• Differentiate renal from radicular pain.

• How would you explain the vomiting?

Page 9: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

• Two types of pain have their origins in the genitourinary organs: – Local – Referred- more common

• Local pain– is felt in or near the involved organ. – the pain from a diseased kidney (T10–12, L1) is

felt in the costovertebral angle and in the flank in the region of and below the 12th rib.

• Referred pain – originates in a diseased organ but is felt at some

distance from that organ. – The ureteral colic caused by a stone in the upper

ureter may be associated with severe pain in the ipsilateral testicle

Page 10: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.
Page 11: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Ureteral pain

• Ureteral pain is typically stimulated by acute obstruction (passage of a stone or a blood clot)

• The physician may be able to judge the position of a ureteral stone by the history of pain and the site of referral.

• If the stone is lodged in the upper ureter, the pain radiates to the testicle, since the nerve supply of this organ is similar to that of the kidney and upper ureter (T11–12).

Page 12: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Ureteral pain• With stones in the midportion of the ureter

on the right side, the pain is referred to McBurney’s point and may therefore simulate appendicitis

• On the left side, it may resemble diverticulitis or other diseases of the descending or sigmoid colon (T12, L1).

Page 13: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Kidney Pain

• Typical renal pain is felt as a dull and constant ache in the costovertebral angle just lateral to the sacrospinalis muscle and just below the 12th rib.

• This pain often spreads along the subcostal area toward the umbilicus or lower abdominal quadrant.

• It may be expected in the renal diseases that cause sudden distention of the renal capsule. – Acute pyelonephritis (with its sudden edema) – acute ureteral obstruction (with its

sudden renal back pressure) – both cause this typical pain.

Page 14: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Kidney Pain• It should be pointed out, however, that many

urologic renal diseases are painless because their progression is so slow that sudden capsular distention does not occur. – Such diseases include :

• cancer• chronic pyelonephritis• staghorn calculus• tuberculosis• polycystic kidney• hydronephrosis due to chronic ureteral

obstruction.

Page 15: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Radicular pain

• Radicular Pain, or Radiculitis, is pain "radiated" along the dermatome (sensory distribution) of a nerve due to inflammation or other irritation of the nerve root at its connection to the spinal column.

• Radicular pain is commonly felt in the costovertebral and subcostal areas.

• It may also spread along the course of the ureter and is the most common cause of so-called “kidney pain.”

Page 16: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Radicular pain

• Every patient who complains of flank pain should be examined for evidence of nerve root irritation.

• Frequent causes are:– poor posture (scoliosis, kyphosis)– arthritic changes in the costovertebral or

costotransverse joints– impingement of a rib spur on a subcostal

nerve– hypertrophy of costovertebral ligaments

pressing on a nerve– intervertebral disk disease

Page 17: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Radicular pain• Pain experienced during the preeruptive phase of

herpes zoster involving any of the segments between T11 and L2 may simulate pain of renal origin.

• Radiculitis usually causes hyperesthesia of the area of skin served by the irritated peripheral nerve.

• This hypersensitivity can be elicited by means of the pinwheel or grasping and pinching both skin and fat of the abdomen and flanks.

• Pressure exerted by the thumb over the costovertebral joints reveals local tenderness at the point of emergence of the involved nerve.

Page 18: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Urinary obstruction

• Normally, urine is formed in the kidneys, flows through the ureters to the bladder, and is released through the urethra.

• A urinary obstruction blocks the normal flow of urine, causing it to back up toward the kidneys.

• Urine flowing the wrong way in the urinary tract can cause infections and kidney damage.

• Obstruction can occur anywhere in the urinary tract:

Page 19: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Urinary obstruction

• Because of their damaging effect on renal function, obstruction and stasis of urinary flow are among the most important urologic disorders.

• Either leads eventually to hydronephrosis, a peculiar type of atrophy of the kidney that may terminate in renal insufficiency or, if unilateral, complete destruction of the organ.

• Furthermore, obstruction leads to infection, which causes additional damage to the organs involved.

Page 20: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Etiology

A. CONGENITAL• The common sites of congenital narrowing:

– externalmeatus in boys (meatal stenosis)– external urinary meatus in girls– the distal urethra (stenosis)– posterior urethral valves– ectopic ureters– ureteroceles – ureterovesical and ureteropelvic

junctions. • Another congenital cause of urinary stasis is

damage to sacral roots 2–4 as seen in spina bifida and myelomeningocele.

Page 21: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

EtiologyB. ACQUIRED• Acquired obstructions are numerous and may be

primary in the urinary tract or secondary to retroperitoneal lesions that invade or compress the urinary passages.

Among the common causes are: (1) urethral stricture secondary to infection or injury (2) benign prostatic hyperplasia or cancer of the

prostate(3) vesical tumor involving the bladder neck or ureteral

orifices(4) local extension of cancer of the prostate or cervix

into the base of the bladder(5) compression of the ureters at the pelvic brim by

metastatic nodes from cancer of the prostate or cervix

(6) ureteral stone(7) retroperitoneal fibrosis or malignant tumor(8) pregnancy

Page 22: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Classification

• Obstruction may be classified according to:– cause (congenital or acquired) – duration (acute or chronic)– degree (partial or complete)– level (upper or lower urinary tract)

Page 23: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Clinical manifestationsUpper tract (ureter and kidney)—• Symptoms of obstruction of the upper tract are

typified by the symptoms of ureteral stricture or ureteral /renal stone.

The principal complaints are :• pain in the flank radiating along the course of the

ureter• gross total hematuria (from stone)• gastrointestinal symptoms• chills• fever• burning on urination• cloudy urine with onset of infection• Nausea, vomiting, loss of weight and strength,

and pallor are due to uremia secondary to bilateral hydronephrosis.

Page 24: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Clinical manifestations• Lower urinary tract obstruction (bladder,

urethra) – can manifest as voiding dysfunction such as

• urgency• frequency• nocturia• incontinence• decreased stream • hesitancy• postvoid dribbling• sensation of inadequate emptying

– Suprapubic pain or a palpable bladder indicates urinary retention.

– Infection may be present, and patients may experience dysuria.

– Hematuria may be present with or without infection.

Page 25: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Clinical manifestaionsSigns of obstruction in the upper urinary

tract:

• An enlarged kidney may be discovered by palpation or percussion.

• Renal tenderness may be elicited if infection is present.

• A large pelvic mass (tumor, pregnancy) can displace and compress the ureters.

• Children with advanced urinary tract obstruction may develop ascites.

• Rupture of the renal fornices allows leakage of urine retroperitoneally;with rupture of the bladder, urine may pass into the peritoneal cavity through a tear in the peritoneum.

Page 26: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Pathogenesis

• The hallmark of urinary tract obstruction is dilation of the collecting system of the kidney which is known as hydronephrosis.  This swelling typically causes pain in the flank or upper abdomen on the affected side. 

Page 27: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Pathogenesis• Progressive back pressure on the ureters

and kidneys can occur and can cause hydroureter and hydronephrosis. The ureter can then become dilated and tortuous, with the inability to adequately propel urine forward.

• Chronic urinary tract obstruction can lead to permanent damage to the urinary tract.

• Infravesical obstruction can lead to changes in the bladder, such as– trabeculation, – cellule formation– diverticula– bladder wall thickening– detrusor muscle decompensation

Page 28: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Pathogenesis

• Hydronephrosis can cause permanent nephron damage and renal failure.

• Urinary stasis along any portion of the urinary tract increases the risk of stone formation and infection, and, ultimately, upper urinary tract injury.

• Urinary tract obstruction can cause long-lasting effects to the physiology of the kidney, including its ability to concentrate urine.

Page 29: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

DIFFERENTIAL DIAGNOSISAbigaile Antonio

Page 30: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Renal infarction

Kidney stones

pyelonephritis Renal abscess

Renal vein thrombosis

Nature of pain

severe, colicky, or constant

sudden onset; colicky,often radiating to groin/abdomen

achy, dull, constant severe, constant

acute onset, severe

Presenting complaints

pain, nausea, vomiting, fever

pain, nausea, vomiting, testicular pain( abdominal and genital examinations are normal)

flank and suprapubic pain;urinary frequency, urgency;dysuria; fever, chills;nausea, vomiting; malaise

pain, fever, chills

pain, fever, oliguria

Flank /CVA tenderness

sometimes sometimes frequent often (patient may have palpable flank mass)

no

Hematuria Rare (less than 1/3 of patients)

Present in 1/3 of cases

Often present Often present

present

Page 31: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Most likely diagnosis

Page 32: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

UROLITHIASIS

• The most common cause of persistent flank pain of sudden onset

• The male-to-female ratio is 2:1.• peak incidence is in the third to fifth

decades of life.• Patients classically present with

sudden-onset flank pain, often radiating to the ipsilateral abdomen and groin.

Page 33: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

• Men may complain of testicular pain and women of labial discomfort.

• The pain is caused by distension of the renal pelvis and upper ureter as well as by peristalsis of the ureter.

• Flank tenderness can be elicited• abdominal and genital examinations

are generally normal. • One-third of patients have gross

hematuria.

Page 34: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

PROGNOSIS

• Most kidney stones pass out of the body without any intervention by a physician.

• Cases that cause lasting symptoms or other complications may be treated by various techniques, most of which do not involve major surgery.

Page 35: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Guide Questions:

• What are the laboratory examinations that you would request?

• What imaging studies would you request?

• Interpret the Imaging Examination.• What are the treatment options?

Page 36: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

LABORATORY EXAMINATIONS

Arvin M. Aningalan

Page 37: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Laboratory Examinations

• Urinalysis• Blood Urea Nitrogen (BUN)• Creatinine• Blood Uric Acid (BUA)• Complete Blood Count (CBC)• Urine Culture• Stone Analysis

Page 38: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Urinalysis

• Determines the Chemical and Microscopic properties of the urine.

MicroscopicRBC

WBC

Casts

Bacteria

Crystals

Chemical ProteinpHSpecific GravitySugar

Page 39: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Urinalysis

• pH – determines the type of crystals and kidney disorders present.

• Crystals – helpful in knowing the origin of the stone.

• WBC – manifest as “pus cells” which may indicate presence of infection.

• RBC - hematuria

Page 40: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

• BUN and Creatinine – evaluates kidney function.

• BUA – determines if there are metabolic disorders that might predispose the patient to stone formation.

• CBC and Urine Culture – test for the presence of infection.

• Stone Analysis – analyzes composition of stone for treatment and preventive measures.

Page 41: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

IMAGING STUDIES

Page 42: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Imaging Studies

• Computed Tomography (CT)• Intravenous Pyelography• Tomography• KUB films and directed

ultrasonography• Retrograde pyelography• Magnetic Resonance Imaging (MRI)• Nuclear Scintigraphy

Page 43: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Noncontrast Spiral CT Scan

• Imaging modality of choice in patients presenting with renal colic.

• Does not depend on experienced radiologic technician to obtain oblique views when there is confusion with overlying bowel gas in a nonprepped abdomen.

• No need for intravenous contrast.

Page 44: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Intravenous Pyelography

• Documents simultaneously nephrolithiasis and upper-tract anatomy.

• Oblique views easily differentiate gallstones from right renal calculi

Page 45: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Renal Tomography

• Useful to identify calculi in the kidney when oblique views are not helful.

• May help identify poorly opacified calculi, especially when interfering abdominal gas or morbid obesity make KUB films suboptimal.

Page 46: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

KUB Films and Directed Ultrasonography

• Ultrasound examination should be directed by notation of suspicious areas seen on a KUB film.

• Distal ureter is easily visualized through the acoustic window of a full bladder

• Edema and small calculi missed on an IVP can be better appreciated

Page 47: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Retrograde Pyelography

• Occasionally required to delineate upper tract anatomy, and localize small or radiolucent offending calculi.

Page 48: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Magnetic Resonance Imaging

• Poor study to document urinary stone disease because urinary stones produces no signal.

Page 49: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Nuclear Scintigraphy

• Bisphosphonate markers can identify even small calculi that are difficult to appreciate on a conventional KUB film.

• However, it cannot delineate upper tract anatomy in sufficient detail to help direct a therapeutic plan.

Page 50: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Interpret

Page 51: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Interpret

Page 52: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

TREATMENT OPTIONS

Page 53: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Treatment Options

1. Conservative Observation2. Dissolution Agents3. Relieve Obstruction4. Extracorporeal Shock Wave

Lithotripsy (ESWL)5. Ureteroscopic Stone Extraction6. Percutaneous Nephrolitotomy

(PCNL)7. Open Stone Surgery

Page 54: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Conservative Observation

• Most ureteral calculi pass and do not require intervention.

• Depends on:– Stone Size (4-5mm have 50-60% chance

of passage)– Shape– Location (At distal ureter = 50%, mid =

25%, proximal = 10%)– Associated ureteral edema

Page 55: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Dissolution Agent

• Depends on stone surface area, stone type, volume of irrigant, mode of delivery.

• Alkalinizing agents:– Sodium bicarbonate (alkalinizes to pH 7.5

and 9.0)– Potassium citrate

Page 56: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Relief of Obstruction

• A patient with obstructive urinary calculi with fever and infected urine requires emergency drainage.

• Retrograde pyelography to define upper tract anatomy followed by retrograde placement of double-J ureteral stent.

Page 57: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Extracorporeal Shock Wave Lithotripsy

• Renal calculi less than 2.0-2.5 cm in aggregate length are best treated with ESWL

• Inferior caliceal calculi have suboptimal stone-free rates.

• uses shock waves to break a kidney stone into small pieces which would then be able to pass in the urine.

• Complications may include pain due to passage of small stones.

Page 58: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.
Page 59: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Ureteroscopic Stone Extraction

• Highly efficacous for lower ureteral calculi

• Uses a small small caliber ureteroscope with balloon dilation.

• Calculi less than 8mm are frequently removed intact.

• Complications may include ureteral injury due to use of flat wire stone baskets which may be twisted producing sharp edges.

Page 60: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Percutaneous Nephrolithotomy

• Treament of choice for Large (>2.5cm) calculi

• A small incision is made into the loin area • An operating channel is placed into the

kidney which the nephroscope passes through into the collecting system of the kidney.

• A continuous irrigation is used to aid vision while retrieving the calculus.

• Laser destruction of the calculus is used if the stone is larger then the operating channel.

Page 61: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.
Page 62: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

Open Surgery

• Classic way to remove calculi• Indicated for large stones, patients

with congenital anomaly that prevents drainage of the kidneys, and as an option when other methods have failed.

• Complications include blood loss from surgery, increase chance of infection, and complications from anesthesia.

Page 63: Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan.

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