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Anatomy-Kidney. Congenital Anomalies:. Agenesis Fusion Dysplasia Simple cysts Polycystic kidney disease. Urolithiasis – Stones:. Urolithiasis – stones:. Infection. Calcium Stone-Formation. Infected Stone-Formation.   Urinary NH 4 +.  CaP supersaturation.   Urinary pH.

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congenital anomalies
Congenital Anomalies:

Agenesis

Fusion

Dysplasia

Simple cysts

Polycystic kidney disease

slide6

Infected Stone-Formation

  Urinary

NH4+

 CaP

supersaturation

  Urinary

pH

Urinary

tract

infection

with a

urea-

splitting

organism

 Nucleation

and

agglomeration

 Urinary

mucoprotein

Abnormal

crystalluria

Infection

stone

 Urinary

citrate

 Inhibitory

activity

 Urinary

phosphate

slide7

Uric Acid Stone-Formation

Age

Sex (M > F)

Genetic disorders

Metabolic disorders

 Dietary purine

 Urinary

uric acid

 Renal NH3

production

 Dietary acid

Uric acid stone

 Urinary

pH

 Uric acid supersaturation

Abnormal

crystalluria

 Urinary

volume

 Fluid intake

 Fluid loss

 Ambient

temperature

slide8

Cystine Stone-Formation

 Tubular

reabsorption

of cystine

 Cystine

supersaturation

Abnormal

crystalluria

Cystine

stone

 Urinary

cystine

Possible

metabolic

factors

clinical picture of stone
Clinical picture of stone
  • Depend on the site
  • Asymptomatic
  • Pain:( kidney dull ach – ureterureteric colic -bladder suprapupic pain reffered to the tip of pines – urethral )
  • Symptoms of complication
  • Hematuria
  • Infection
  • Migration
  • Obstruction
  • Malignancy
diagnostic evaluation for stone
Diagnostic evaluation for stone
  • History, P/E
  • Urine
    • PH>7.5 Infected stones
    • PH<5.5 Uric acid
    • Sediment for crystalluria
    • Urine culture –urea splitting organisms
  • Biochemical screen
    • U&E, Ca,PO4, uric acid, bicarbonate
  • PTH if Ca is elevated
  • Radiological (plain x ray – IVU- ascending urogram-CT)
  • US
  • Stone analysis
treatment
Treatment

I)For acute attack: analgesics and

II)Definitive treatment

  • Conservative : <1cm with no complication and no distal obstruction

( fluid ,antispasmodics, change urine PH, antibiotics & follow up )

B)Active (ESWL-Percutanousenephro- lithotomy, nephro- lithotomy ,Pyelo-lithotomy,Retrograde endoscopy, uretrolithotomy )

III)Treatment of complication( calculasanuria, hydronephrosis and pyonephrosis)

IV)Prevention of recurrence etiology

Multiple : urethral –ureter-kidney-bladder

renal tumors
Renal tumors
    • Benign (rare!)
    • Adenoma, oncocytoma, angiomyolipoma, fibroma
  • Malignant:
    • Renal cell carcinoma (common – adults)
    • Wilm`stumor (childhood)
    • Transitional cell carcinoma of renal pelvis
wilm s tumor
Wilm’s Tumor

Nephroblastoma.

Synonyms:

Most common renal tumor of childhood. Peak age - 2.5 - 3.5 years.

Incidence:

Etiology:

Embryonic renal tissue (metanephric blastema). Genetic abnormalities.

Clinical

Features:

radiology

Palpable abdominal mass. Abdominal pain, fever, anorexia, nausea/vomiting.

CT ,us

No specific clinical laboratory findings. Diagnosis by radiographic techniques.

Path:

Gross: Solitary/multiple cystic mass, sharply delineated. Soft, bulging, gray-white with focal hemorrhage and necrosis.

Course:

5-yr. Survival 80%.

Metastases to lung, liver, bone, brain.

Treatment:

Resection with chemotherapy ± radiotherapy.

renal cell carcinoma
Renal Cell Carcinoma:

Hypernephroma, clear cell carcinoma.

Synonyms:

5th and 6th decades, most common primary renal malignancy.

Incidence:

Etiology:

Cells of proximal convoluted tubule.

Risk factors are smoking, obesity, analgesic abuse

Clinical

Features:

Hematuria*, flank pain, palpable mass. Frequently metastasize (lungs, bone, skin, liver, brain).

Lab:

Gross or microscopic hematuria.

CT

Renal mass

Clinical

Course:

5-yr. survival 40%.

Poor prognosis with metastases.

Treatment:

Chemotherapy, surgery, immunotherapy.

Introduction

urinary injury
Urinary Injury
  • Urethral Injury
  • Bladder Injury
  • Urteric
  • Kidney Injury
  • Iatrogenic Vs traumatic
urethral trauma
Urethral Trauma
  • Almost exclusively in male
  • Significant morbidity
    • Stricture
    • Incontinence
    • Impotence
  • If unrecognized:
    • Converting partial to complete tear
  • Foley catheter implication
anatomy
Anatomy

Prostatic

Bladder

Symphysis

posterior urethra
Posterior Urethra
  • Violent external force
  • Pelvic fracture in 90%
  • Gross hematuria in 98%
  • Inability to void
  • Blood at urethral meatus
  • Pelvic / suprapubic tenderness
  • Penile / scrotal / perineal hematoma
  • Boggy / high-riding prostate/ ill-defined mass on rectal examination
diagnosis retrograde urethrogram
Diagnosis:Retrograde Urethrogram
  • Pretest KUB film
  • Supine position
  • Injection of 25ml of water-soluble contrast
  • Post-voiding x-ray.
retrograde urethrogram interpretation
Retrograde Urethrogram:Interpretation
  • Contrast extravasation + Contrast in bladder
  • Contrast extravasation only

PARTIAL Tear

COMPLETE Tear

partial tear
Partial Tear
    • careful passage of 12-14 Fr. Foley.
  • If any resistance:Suprapubic catheters Surgical approach / Endoscopy Delayed repair usually
complete tear
Complete Tear

Suprapubic catheters. Surgical approach / Endoscopy Delayed repair usually

  • If Foley already there and suspected
    • LEAVE FOLEY IN PLACE
anterior urethra
Anterior Urethra
  • More common than posterior
  • Direct trauma
  • Usually NO pelvic fracture
  • Blood at meatus
  • Unable to micturate
  • Penile/Scrotal/Perineal
    • Contusion
    • Hematoma
    • Fluid collection
  • NO Foley if injury suspected
  • Retrograde Urethrogram
    • Surgical Treatment
bladder trauma
Bladder Trauma
  • Adult: Extraperitoneal organ
  • Bladder dome = weakest point
  • Blunt: 60-85%
  • Important to recognize
    • Pelvic/abdominal wall abscess/necrosis
    • Peritonitis
    • Sepsis / Death
types of rupture
Types of rupture
  • Extraperitoneal
    • Most common
    • Pelvic fracture in 89-100%
  • Intraperitoneal
    • Extravasation of urine in abdomen
    • Sudden force to full bladder
    • Associated injuries
    • Mortality (20%)

Investigation

  • US
  • Cystography: Gold standard
  • CT Cystography : New trend
  • ABCD for polytrauma
  • Exeploration and repair
kidney injury
Kidney Injury
  • Kidney is :

Retroperitoneal organ

Cushoned by perinephric fat and Gerota’s fascia

Along T10 - L4

Ribs 10-12

Fixed only through pedicle.

  • Blunt trauma: 80-90%
  • MUST be suspected if
    • Trauma to back / flank / lower thorax / upper abdomen
    • Flank pain / low rib fracture
    • Hematuria / Ecchymosis over the flanks
    • Lumbar transverse process fracture
investigation
Investigation
  • IVP
    • Used to be intial exam of choice.
    • Very poor sensitivity for penetrating injury
    • Limitation in staging renal injuries
    • Not 1st choice anymore. Only if pt unstable.
  • Contrast CT
    • Study of choice if stable
    • More sensitive and specific for staging
    • Detects other abdominal injuries
management
Management…
  • Absolute indication for Surgery:
    • Uncontrollable renal hemorrage
    • Multiply lacerated, shattered kidney
    • Main renal vessels avulsed
    • Penetrating injuries usually
  • Grade I-II
    • conservative
  • Grade III-IV
    • Conservative if stable hemodynamically vs. surgery
  • Grade V
    • Surgery
causes of obstructive uropathy
Causes of Obstructive Uropathy

Anatomical

Obstruction

within the lumen

in the wall

out side

Pathological

congenital

tumor

trauma

inflammation

vascular

others

slide38

• Urinary Tract Obstruction:

• Recognition of obstruction is important since it increase the chance of infection and stone formation. In addition unresolved obstruction almost always lead to permanent renal atrophy fortunately many causes of obstruction are surgically correctable or medically treatable.

• It can be sudden or insidious, partial or complete,

unilateral or bilateral. It may occur at any level of the urinary treat from the urethra to the renal pelvis.

• It can be caused by lesion that are intrinsic to urinary tract or extrinsic lesion that compress the ureter.

urinary tract infection40
Urinary Tract Infection

Definition

Women: Presence of at least 100,000 colony-

forming units (cfu)/mLin a pure

culture of voided clean-catch urine

Men: Presence of just 1,000 cfu/mLin a pure

culture of voided clean-catch urine

indicates urinary tract infection

risk factors for uti
Risk Factors for UTI
  • Female,
  • Advanced Age,
  • Fecal incontinence/impaction,
  • Incomplete bladder emptying or neurogenicbladder,
  • Vaginal atrophy/estrogen deficiency,
  • Pelvic prolapse / cystocele,
  • Insufficient fluid intake/dehydration,
  • Indwelling Foley catheter or urinary catheterization or instrumentation procedures,
  • Diabetes or immunosuppression,
  • Benign prostatic hypertrophy
  • Bladder or prostate cancer,
  • Urinary tract obstruction
  • Spinal cord injury
causative pathogens
Causative Pathogens
  • Escherichia coli — gram (-) etiologic agent in ~ 80% of all UTI’s
  • Source of microbial invasion is retrograde colonization

Polymicromialbacteriuria

  • Contamination most frequent cause of multiple microorganisms
  • Sours :fistulas, urinary retention, infected stones, or catheters
symptoms versus asymptomatic bacteriuria
Symptoms versus Asymptomatic Bacteriuria

Asymptomatic Bacteriuria (ASB)

  • Defined as the presence of bacteria in urine of patients who do not have dysuria, urinary frequency, urgency, fever, flank pain, or other symptoms related to irritation of the urethra, bladder, or kidney
  • Strictly defined—exists when 2 urine cultures done with clean-catch specimens are positive in a patient who has no urinary tract symptoms

signs and Symptoms

  • Dysuria, urinary frequency, urgency
  • Clarity of urine
    • cloudy, milky or turbid → bacteriuria
      • Cloudiness, however, can occur in normal urine—mucus, epithelial cells
      • Cloudy character, alone or with (+) dipstick analysis → further lab analysis
  • Bloody
    • Hematuria not always indicative of infection; possibly irritation or medication related
  • Malodorous
  • Pain
    • Despite limitations of assessment in the elderly, suprapubic, flank or CVA pain can indicate UTI
  • Incontinence
    • May be caused by UTI or the altered mental status that that occurs with the elderly

Elevated temperature

diagnostic criteria
Diagnostic Criteria

Pyuria

  • Associated with presence of both symptomatic and asymptomatic UTI’s in elderly
  • Level of pyuria is ↑ when infected with a gram negative organism
laboratory analysis
Laboratory Analysis

Dipstick Testing

Used in primary care & LTC settings. But for institutionalized adults, urinalysis is preferable.

  • Chemically impregnated reagent strips (UA Chemstrip Screen) provide

preliminary/quick determinations of:

pH bilirubin

protein blood

glucose *nitrite

ketones *leukocyte esterase

urobilinogen specific gravity

Routine Urinalysis—Key Indicators of Infection

  • Urine collection 1st morning specimen is best
  • Appearance Cloudy, may not indicate WBC’s
  • Odor Normal → faint odor when freshly voided

Foul-smelling—often presence of bacteria which splits urea to form ammonia

  • pH control of pH → manages bacteriuria, renal calculi & drug Rx
  • Blood Always an indicator of kidney/UT damage
  • WBC’s
laboratory analysis46
Laboratory Analysis
  • Urine Culture and Sensitivity

Traditional gold standard for significant bacteriuria >100,000 cfu/mL of urine.

  • Complete Blood Count with Differential
    • Indicated to R/O bacterial infection supports treatment plan Careful evaluation of WBC & differential (left shift)
  • Electrolytes
    • R/O dehydration & if IV fluids replacement needed
  • BUN, Creatinine
    • Determine ↓ renal function for nephrotoxic medications
  • Blood Culture
    • Identify bacteremic organism in suspected urosepsis
treatment plan
Treatment Plan
  • Early detection to prevent systemic infection, bacteremia
  • Initiation of antibiotic treatment is recommended for a clinically-diagnosed UTI.
  • AB for at least10 days, as short-term therapy, may not be as effective.
  • Ten-14 days, if indicated, for complicated UTI.
  • Adjust medication when urine C&S is final
  • Selection of antibiotic must be individualized and consider:
    • Side effect profile
    • Cost
    • Bacterial resistance
    • Likelihood of compliance (convenience, fewer pills/day ↑’s compliance)
    • Effect of impaired renal function on dosing
    • Possible adverse drug reactions ↑ in elderly (multiple drugs, co-morbidities.
prevention
Prevention

Indwelling-Catheterization

Foley catheterization should be avoided if at all possible

  • Most effective means of UTI prevention is limitation of chronic indwelling catheters.
prostate
Prostate
  • Anatomy – 5 lobes.
  • Median/Posterior – (BPH/Cancer)
  • Hormone response – Estrogen like
  • Enlargement – Inflammation / growth
  • Neoplastic / Non neoplastic growth.

BPH / Cancer.

bph bignin prostatic hyperplasia
BPH Bignin Prostatic Hyperplasia
  • Common non-neoplasticEnlargement.
  • Involves peri urethral zone.
  • BPH is common as men age.
  • 75% among men aged 70-80years
  • Over 90% in people aged over 90y
  • Rare before the age of 40y.
bph pathophysiology
BPH-Pathophysiology:
  • Excess hormones – estrogen like.
  • Nodular hyperplasia of glands & stroma.
  • From normal 20 to 30 50 to 100 gm.
  • Not a premalignant condition
bph mechanism
BPH - Mechanism
  • Hormonal imbalance with ageing.
  • Estrogen sensitive peri-urethral glands.
  • Accumulation of dihydrotestosterone in the prostate and its growth-promoting androgenic effect
bph mechanism of obstruction
BPH-mechanism of obstruction:

Median lobe (3rd lobe)

Ball valve mechanism

Press upon the prostatic urethra.

Obstruction - difficulty on urination

Dysuria, retention, dribbling, nocturia

Infections, hydronephrosis, renal failure.

bph complications
BPH-Complications:
  • Urethral compression
  • Bladder hypertrophy
  • Trabeculation
  • Diverticula formation
  • Infection
  • Stone formation
  • Hydroureter – bilateral
  • Hydronephrosis
adenocarcinoma of the prostate
Adenocarcinoma of the Prostate:
  • Adenocarcinoma of the prostate is common in elderly men.
  • It is rare before the age of 50, but seen in over half of men 80 years old.
  • Many of these carcinomas are small and clinically insignificant.
s ymptoms of prostate enlargement
SYMPTOMS OF PROSTATE ENLARGEMENT

Weak urine stream

Night time urination

Frequent or urgent urination

Starting and stopping of urination

Hesitancy of stream

Sensation of incomplete bladder emptying

Painful or burning urination

diagnosis
Diagnosis:
  • Digital examination
  • Ultrasonography (transrectal) -
  • Tumor Marker – PSA
  • Biopsy - TURP
  • None of these methods can reliably detect small cancers.
  • Occult cancer is more common than clinical ca.
t hree treatment categories of bphp
THREE TREATMENT CATEGORIESof BPHP

Drug therapy

Surgery(TURP), OPEN PROSTATECTOMY

Minimally invasive treatments Transurethral microwave (TUMT) Transurethral needle ablation (TUNA) Interstitial laser coagulation (ILC)

e arly diagnosis of cancer prostat
EARLY DIAGNOSIS of cancer prostat

Annual prostate exams after age 50

See your doctor immediately if you

have any symptoms

slide61
Pain 

Renal PainUreteric pain Prostatic Pain  Penile Pain

Testicular Pain   

hematuria
Hematuria :
  • In adults, should be regarded as a symptom of urologic malignancy until proved otherwise
    • Is the hematuriagross or microscopic?
    • Timing: (beginning or end of stream or during entire stream)?
    • Is it associated with pain?
    • Is the patient passing clots?
    • If the patient is passing clots, do the clots have a specific shape?
  • HematuriaInitial hematuria:
    • usually arises from the urethra
    • least common
    • usually secondary to inflammation.
  • Total hematuria
    • most common
    • bladder or upper urinary tracts.
  • Terminal hematuria
    • the end of micturition
    • secondary to inflammation bladder neck or prostatic urethra.
kidney
Kidney

• Trauma: mild to moderate trauma commonly causes renal bleeding, severe injuries may not bleed (avulsed kidney complete disruption).

• Tumours: may be profuse or intermittent.

Renal cell carcinoma: associated mass, loin pain, clot colic or fever, occasional polycythaemia, hypercalcaemia and hypertension.

TCC: characteristically painless, intermittent haematuria.

• Calculus: severe loin/groin pain, gross or microscopic, associated infection.

• Glomerulonephritis: usually microscopic, associated systemic disease (e.g. SLE).

• Pyelonephritis .

• Renal tuberculosis: sterile pyuria, weight loss, anorexia, PUO, increased frequency of micturition day and night.

• Polycystic disease : palpable kidneys, hypertension, chronic renal failure.

• Renal arteriovenous malformation or simple cyst: painless, no other symptoms.

• Renal infarction: may be caused by an arterial embolus, painful tender kidney.

slide64

Ureter

• Calculus: severe loin/groin pain, gross or microscopic, associated

infection.

• TCC

Bladder

• Calculus: sudden cessation of micturition, pain in perineum and tip of penis.

• TCC: characteristically painless, intermittent haematuria, history of work in rubber or dye industries.

• Acute cystitis: suprapubic pain, dysuria, frequency and bacteriuria.

• Interstitial cystitis : may be autoimmune, drug or radiation induced, frequency and dysuria common.

• Schistosomiasis : history of foreign travel, especially North Africa.

slide65

Prostate

• BPH: painless haematuria, associated obstructive symptoms, recurrent UTI.

• Carcinoma .

Urethra

• Trauma: blood at meatus, history of direct blow to perineum, acute retention.

• Calculus .

• Urethritis .

lower urinary tract symptoms
Lower Urinary Tract Symptoms  
  • Irritative Symptoms
    • Urinary frequency
    • Nocturia
    • Frequency
    • Dysuria: painful urination
    • Incontinence
      • Stress
      • Urge

Obstructive Symptoms  

  • Decreased force of urination
  • Urinary hesitancy
  • Intermittency
  • Post void dribbling
  • Straining
  • Enuresis  
  • Urinary incontinence that occurs during sleep
  • Mostly in children up to 5 years