CES: Genitourinary System Tom Heaps Consultant Acute Physician.
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Transcript of CES: Genitourinary System Tom Heaps Consultant Acute Physician.
CES: Genitourinary System
Tom HeapsConsultant Acute Physician
Outline Basic anatomy
Functional physiology
Symptoms
Examination
Nephrolithiasis
Obstruction
BREAK
Acute Kidney Injury (AKI)
Basic anatomy
Kidneys
Ureters
Urethra
Bladder
Functional anatomyOuter cortex
Inner medulla
Nephron
Ureter
Renal Pelvis
Calyces
Nephron: the functional unit of the kidney
Glomerular filtrationNet filtration pressure at the glomerulus
= blood hydrostatic pressure – colloid oncotic pressure – capsular hydrostatic pressure
= 55mmHg – 30mmHg – 15mmHg
= 10mmHg
Large surface area and porous membrane
glomerular filtration rate (GFR) of 125 mL/min in normal health
fluid volume of ~180L/day enters glomerular capsule
GFR is regulated by the body depending on circulating volume and [Na+]
Efferent
arteriole
Afferent arteriole
Filtration
Vasodilatation mediated by
prostaglandins
Vasoconstriction mediated by angiotensin II
ACE-inhibitors reduce production of angiotensin II
from angiotensin I by ACE
NSAIDs reduce prostaglandin
synthesis
Glomerula
r hydrostatic pressure
and filtration
Glomerula
r hydrostatic pressure
and filtration
Role of the kidneys
Production and excretion of urine
- Removal of waste e.g. creatinine, urea, uric acid
- Maintenance of homeostasis
Regulation of ECF volume and composition:
- Control of ion balance and pH
- Control blood volume / blood pressure
- Control osmolality (excretion / resorption of Na+)
Production of hormones / vitamins
- Renin and erythropoietin (EPO)
- Vitamin D3
GU Symptoms 1
Polyuria Too much urine DM, DI, hypercalcaemia, post-obstruction
Oliguria / Anuria Not enough / no urine Dehydration , AKI,
obstruction
Frequency Going too often Infection, stones, detrusor instability
Urgency Having to go quickly! Infection, detrusor instability
Dysuria Painful / burning micturition Infection
Nocturia Going >2x per night
Outflow obstruction, infection, stones,
detrusor instability, causes of polyuria
Hesitancy Difficulty starting Outflow obstruction
Terminal Dribbling Weak stream Outflow obstruction
Incontinence Loss of control Urge, stress, neurological problems, dementia
GU Symptoms 2
Haematuria Microscopic or Macroscopic
Infection, stones, tumours, trauma,
glomerulonephritis, coagulopathy / anticoagulants
Renal Angle Pain
Renal: pyelonephritis, abscess, stones (renal colic), hydronephrosis,
cysts, tumours, infarction
Non-renal: cholecystitis, hepatitis, pancreatitis,
splenic infarction, gynaecological, shingles, basal pneumonia, MSK
Urethralgia Pain along the urethra +/- discharge
Infection / urethritis, STI, stone, foreign body,
tumour
Orchalgia Testicular pain Epididymo-orchitis, tumour, trauma, torsion
Prostatitis
Perineal pain, dysuria, obstructive
symptoms, tenderness on DRE
Urogenital infection or instrumentation
Additional GU History
Hypertension, diabetes
Family and congenital history
Drug History
Sexual and travel history
Systems review
GU Examination
Full systems examination focusing on abdomen
- Inspection
GU Examination
Full systems examination focusing on abdomen
- Inspection
- Palpation
- Percussion
- Auscultation
Costovertebral angle between lower border of 12th rib and lateral border of erector spinae
Pain / tenderness, Murphy’s punch +ve
Kidneys usually not palpable unless hydronephrosis, tumour, cystic disease
Palpate specifically for bladder distension in the elderly
GU Examination
Full systems examination focusing on abdomen
- Inspection
- Palpation
- Percussion
- Auscultation
Perineum / Scrotum / Testicles
Vagina / Penis
Digital rectal examination (DRE)
- Prostatic enlargement and / or tenderness
- Constipation
- Masses
Nephrolithiasis (urinary tract stones)
>80% are calcium stones, majority of these are calcium oxalate
Usually asymptomatic until they pass into ureter
- Pain (may be excruciating) and nausea
- Waxing and waning (renal / ureteric colic)
- Abdomen / flank testicle / penis / labia (‘loin to groin’)
- Haematuria, frequency, urgency, dysuria, strangury
Non-contrast CT urogram is Ix of choice (sensitivity 88%, specificity 100%)
USS if radiation an issue (sensitivity 57%)
Plain AXR no longer has a role (if CT available)
Conservative Rx with hydration, NSAIDs / opioids, tamsulosin / nifedipine
Urgent urological referral if AKI, sepsis, stone >10mm
Urinary retention / obstruction
Acute vs. chronic, unilateral vs bilateral
Kidney / ureter – stones, TCC, extrinsic tumour, retroperitoneal fibrosis
Bladder – stones, tumour, blood clots, neurological, drugs, constipation
Urethra – prostate cancer, BPH, stricture, stone
Pain (may be absent in chronic retention and dementia)
Oligo-anuria and AKI, haematuria, hypertension,
DRE is mandatory, bladder scan then USS abdomen / pelvis
IV fluids, urinary catheter, fluid balance, -blockers and antispasmodics
Treat precipitant (pain, infection, constipation, drugs etc.)
Be vigilant for post-obstructive diuresis and decompression haematuria
Other Rx e.g. ureteric stent, nephrostomy
Acute Kidney InjuryTom Heaps
Consultant Acute Physician
Clinical Case
82-year-old male presenting with confusion and vomiting
PMHX: T2DM, hypertension, heart failure, BPH
DHX: Aspirin, metformin, ramipril, bendroflumethiazide, bisoprolol
RR 24, SpO2 94% (air), T 38.5C, BP 101/50mmHg, HR 119/min
Urine dip: leuc +++, nit +ve, blood +, protein ++
Na+ 144mmol/L
K+ 5.9mmol/L
urea 15.4mmol/L
creatinine 142μmol/L
With reference to this case…
GROUP 1: Is this AKI? What are the definitions of AKI?
GROUP 2: What are the risk factors for AKI? Which apply to this case?
GROUP 3: What are the common causes of AKI? Which apply to this case?
GROUP 4: What are the 6 most important steps in management of AKI?
GROUP 5: What are the complications of AKI and how are they treated?
AKI 1: definitions
calculated GFR is usually more accurate than serum creatinine in estimating renal function but most definitions of AKI rely on creatinine measurement
KDIGO (Kidney Disease Improving Global Outcomes) definition of AKI:
Stage of AKI
Serum Creatinine (SCr) criteria
Urine output criteria
1
increase ≥ 26 μmol/L within 48h or
increase ≥1.5x to 1.9x reference SCr
<0.5 mL/kg/h for >6 consecutive hrs
2 increase ≥ 2x to 2.9x reference SCr
<0.5 mL/kg/h for >12 hrs
3
increase ≥3x reference SCr or
increase ≥354 μmol/L or commenced on renal
replacement therapy (RRT) irrespective of stage
creatinine rise by ≥ 26µmol/L within 48 hours or;
creatinine rise ≥ 1.5-fold from the reference value* which is known or presumed to have occurred within one week or
urine output < 0.5mL/kg/h for >6 consecutive hours
*reference serum creatinine is the lowest creatinine value recorded within 3m of the event
AKI 2; risk factors
CKD (especially if eGFR <60mL/minute) heart failure liver disease diabetes history of AKI neurological / cognitive impairment or disability hypovolaemia use of drugs with nephrotoxic potential (NSAIDs, ACE-i,
diuretics etc.) use of iodinated contrast agents within the past week symptoms / history of or conditions predisposing to
urological obstruction sepsis deteriorating early warning scores (MEWS) age ≥ 65
AKI 3: causes
Pre-Renal (75%)
•hypotension•hypovolaemia•redistribution•decreased cardiac output•renal artery stenosis or thrombosis
Renal (20%)
•nephrotoxic medications•glomerulonephritis•interstitial nephritis•vasculitis•ischaemia•rhabdomyolysis
Post-Renal (Obstructive)
(5%)•urethral e.g. BPH•bladder e.g. stones, blood clots, tumours•ureteric e.g. stones, fibrosis, malignancy•PUJ obstruction•intra-tubular e.g. crystals•renal vein thrombosis•abdominal compartment syndrome
AKI 4: management principles
1. Treat underlying cause
2. IV fluids- restore and maintain renal perfusion (may require
vasopressors)- balanced crystalloids e.g. Hartmann’s + / - sodium
bicarbonate
3. Stop nephrotoxics and adjust doses of other medications if necessary
4. Monitoring - strict fluid input / output monitoring- consider urinary catheter- monitor for and treat complications of AKI
5. USS urinary tract
6. Renal referral + / - RRT
selected cases only
Myths regarding balanced crystalloids…
‘you can’t give Hartmann’s to patients with hyperkalaemia because it contains potassium’
‘you can’t give Hartmann’s to patients with lactic acidosis because it contains lactate’
Haemodialysis (HD) vs Continuous Veno-Venous Haemofiltration (CVVH)
Indications for Renal Replacement Therapy (RRT) in AKI persistent hyperkalaemia (K+ >7.0mmol/l) severe refractory metabolic acidosis (pH <7.1, HCO3
- <12 or BE < -10 )
refractory pulmonary oedema uraemic complications (urea usually >45mmol/L)
Prevention is better than cure…55% of AKI is avoidable (including 30% of deaths due to AKI)
AKI 5: complications
hyperkalaemia (K+ >5.5mmol/L)
other electrolyte abnormalities e.g. hyperphosphataemia, hyponatraemia
metabolic acidosis- IV fluids, IV bicarbonate (especially if hyperkalaemia),
RRT
fluid overload / pulmonary oedema- diuretic / GTN (often ineffective), RRT
uraemia: encephalopathy, pericarditis, bleeding
mortality- overall mortality 26% (severity of illness and / or frailty
of patient) - 16% in Stage 1, 33% in Stage 2, 36% in Stage 3, 58% if
RRT required
?QUESTIONS?