- How do you assess a middle aged patient who presents with an episode of microscopic haematuria?
Microscopic haematuria is the presence of minute amounts of RBCs in urine that are only detected by microscopy or urine dipstick.
As there can be many causes of microscopic haematuria a thorough history, clinical examination and relevant investigations are necessary to make an assessment.
I would want to know how and why the original sample was taken.
In my history:
I want to know if there are any associated symptoms because:
- dysuria, frequency, urgency and fever would lead me to think UTI
- hesitancy and dribbling in a male would lead me to think prostatic issues
- associated flank pain would lead me to think nephrolithiasis or pyelonephritis
- recent URTI for post-strep glomerulonephritis
- constitutional signs for urinary tract malignancies
- signs of trauma
In a female pt I would take a menstrual hx to ensure there is no contamination and a pregnancy test to ensure further investigations dont involve radiation if it is positive.
I’d also ask PMHx, family, lifestyle and social history to assess for other causes.
My examination would involve:
- vitals
- General inspection
- abdominal exam
- inspection of external genitalia
- PR exam in males
Investigations would include:
- urinalysis and Urine MCS
- FBC (anaemia, leucocytosis)
- coags
- UEC (renal function)
- CRP
- PSA in males
- renal USS
- consider CT abdo/pelvis- initially without intravenous contrast to evaluate for nephrolithiasis and hydronephrosis and then after intravenous contrast administration to evaluate for renal and urothelial abnormalities- stones and masses.
- A 60 year-old woman attends ED with a three week history of blood in the urine, including some clots. She has had an intermittent urinary stream in the past 24 hours, and is complaining of suprapubic pain when voiding. She has had frequency and urgency of voiding for one month. There is nothing remarkable in the rest of her history. On examination, she is pale, pulse of 100 bpm, BP 105/70 mmHg, her Hb is 8.2 g/dl with a pattern consistent with iron deficiency, rest of her blood work is normal.
- What is the important diagnosis to exclude and what investigations do you want to do?
The most important diagnosis to exclude is urological malignancy. This includes Transitional cell carcinoma of the bladders and ureters and Renal Cell Carcinoma of the kidneys.
After a good clinical history and examination to rule in or out other differentials based on risk factors, symptoms and clinical signs the investigations I would consider are:
- FBC, UEC, LFTs. Coags, CRP
- urinalysis and urine MCS
- urine cytology - three mid-morning, midstream urine samples on three consecutive days
- USS of urinary tract
- CT Kidney, Ureters and Bladder if positive cytology, abnormal USS or high clinical suspicion
- You are asked to see a 75 year-old man in ED. He has not been able to urinate for 12 hours and is in acute pain. The ED doctor referring him has excluded all other conditions, but has had to attend a resus room case before considering his urinary tract, no imaging modality is available.
What will you do to assess this man and how will you treat him?
I’d start of by taking a history focusing on previous history of retention or lower urinary tract symptoms prostate disease (hyperplasia or cancer), pelvic or prostate surgery, radiation, or pelvic trauma.
I’d specifically ask about the presence of hematuria, dysuria, fever, low back pain, neurologic symptoms,
OR rash (neuritis induced by herpes zoster of S2-S4 dermatome resulting in dextrusor arreflexia and flaccid bladder) AND a the medications they use.
My examination would include: - vitals - abdo exam with palpation of the bladder and lower abdo specifically - PR exam AND Neurological exam
Investigations would include:
- FBC, UEC
- bedside bladder USS if possible
BUT MORE IMPORTANTLY as
the patient is in discomfort and unable to void, a urethral catheter should be placed regardless of the estimated volume on bladder ultrasound.
Upon placement of a urethral catheter, the initial amount of urine drained should be noted. Patients with volumes <200 mL likely do not have acute urinary retention.
Suprapubic is used if urethral catheter failure or the patient has had recent urological surgery
BUT Urological referral will be needed to do this
• Analgesia – if the pain is not completely relieved by the decompression
and urology REFERRAL for FOLLOW UP
EXTRA
Aetiology of acute urinary retention:
• Obstructive
o Men: BPH, meatal stenosis, phimosis, paraphimosis, prostate cancer, constricting bands
o Women: Organ prolapse, pelvic mass, retroverted impacted gravid uterus
o Both: aneurysmal dilations, bladder calculi, bladder neoplasm, faecal impaction, retroperitoneal masses, urethral strictures, foreign bodies, stones, oedema
o Infectious/Inflammatory causes
• Pharmacological
o Anticholinergics, antidepressants, antihistamines, antiarrhythmics, antiparkinsonian agents, antipsychotics, hormonal agents, muscle relaxants, sympathomimetics, antihypertensives
• Neurological
o Autonomic or peripheral nerve lesions
o Brain of spinal cord disease
Interruption of innervation to detrusor muscle
Incomplete relaxation of urinary sphincter
Inefficient detrusor contraction
- An 81 year-old man presents to the ED complaining of difficulty passing urine. This has been a problem for six months, and is getting worse. He has a poor flow when he passes water, is getting up at night more frequently, and has wet the bed on several occasions in the last month. His bowels open regularly, every second day, and have not changed. On examination, there is a palpable, non-tender, suprapubic mass which is dull to percussion. The rest of the abdominal and systemic exams are normal. DRE reveals a large, smooth, soft prostate gland and nothing else.
- What is the diagnosis?
- Why is he complaining of bedwetting?
The diagnosis is Chronic urinary retention due to benign prostatic hyperplasia (BPH)
He is complaining of bed wetting because:
- the bladder outlet obstruction caused by BPH causes incomplete emptying and chronic urinary retention as a result of increasing levels of residual volume.
- This leads to bladder distention, an atonic bladder and ultimately over flow incontinence.
- The nocturnal enuresis (involuntary bed wetting) is a common presentation due to relaxation of the pelvic floor muscle during sleep in combination with the overfilled bladder.
EXTRA
Clinical Presentation of chronic urinary retention:
Irritative symptoms
o Frequency (polyuria and nocturia)
o Urgency
o Dysuria
Obstructive symptoms o Hesitancy o Straining o Intermittent stream o Dribbling o Sensation of incomplete voiding
•Haematuria
- An 81 year-old man presents to the ED complaining of difficulty passing urine. This has been a problem for six months, and is getting worse. He has a poor flow when he passes water, is getting up at night more frequently, and has wet the bed on several occasions in the last month. His bowels open regularly, every second day, and have not changed. On examination, there is a palpable, non-tender, suprapubic mass which is dull to percussion. The rest of the abdominal and systemic exams are normal. DRE reveals a large, smooth, soft prostate gland and nothing else.
- What is the diagnosis?
- What is the management?
The diagnosis is Chronic urinary retention due to benign prostatic hyperplasia (BPH).
If the pt is presenting with inability to void, pain or discomfort then catheterisation may be appropriate.
Otherwise treatment options can include:
- watchful waiting and behavioral changes.
- Pharmacological therapy
- OR surgery
Behavioral changes can include:
- voiding in the sitting position (rather than standing)
- Avoiding fluids prior to bedtime or before going out
- Double voiding to empty the bladder more completely
The decision to medically treat benign prostatic hyperplasia (BPH) balances the severity of the patient’s symptoms with the potential side effects of therapy. Unless patients have developed bladder outlet obstruction, BPH only requires therapy if symptoms have a significant impact on a patient’s quality of life.
This can be measured using the International Prostate Symptom Score where a score above 8 may indicate patients that would benefit from medical or surgical therapy.
Medications commonly used to treat lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH) include:
- Alpha-1-adrenergic antagonists (immediate but can impact BP)
- 5-alpha-reductase inhibitors (requires 6-12 months before symptom improvement)
- Anticholinergic agents can be used in men who have predominately irritant symptoms,
- AND phosphodiesterase-5 inhibitors are an option in men who also have erectile dysfunction
Prostatic tissue can be removed (ie, resected) or destroyed (ie, ablated) using a variety of techniques, such as:
- transurethral resection of the prostate (TURP),
- transurethral laser enucleation ,
- plasma or photoselective vaporization (PVP),
- transurethral microwave thermotherapy (TUMT)
Other non-transurethral procedures include simple prostatectomy (open, laparoscopic, or robotic) and prostatic arterial embolization (PAE)
Indications for surgery:
o Moderate to severe symptoms that are bothersome to the patient
o Acute urinary retention refractory to medical management
o Renal insufficiency secondary to BPH
o Median lobe configuration leading to occlusion of bladder neck when the bladder contracts
- An 81 year-old man presents to the ED complaining of difficulty passing urine. This has been a problem for six months, and is getting worse. He has a poor flow when he passes water, is getting up at night more frequently, and has wet the bed on several occasions in the last month. His bowels open regularly, every second day, and have not changed. On examination, there is a palpable, non-tender, suprapubic mass which is dull to percussion. The rest of the abdominal and systemic exams are normal. DRE reveals a large, smooth, soft prostate gland and nothing else.
- What is the diagnosis?
- What features of the prostate, if found on examination, would make you concerned about prostate cancer?
- Diagnosis: Chronic urinary retention due to benign prostatic hyperplasia (BPH)
- Concerning prostate features would include:
- presence of hard irregular nodules
- asymmetrical shape
- loss of median furrow
- palpable local invasion into pelvis or posteriorly around the rectum.
- What are the advantages of screening a 55 year-old man with a PSA test for prostate cancer?
• Low risk investigation
•Easily conducted and widely available
•PSA elevation can precede clinical disease by 5 – 10 years
•Results are reproducible and not-operator dependent
•There is a small mortality benefit – For every 1000 men aged 55-65 screen, 4 will eventually die of prostate cancer and only one man will possibly be saved through testing
•There is an increased benefit from screening high-risk men (people with a FHx)
- can be used as a baseline test and a test to monitor cancer development.
- What are the disadvantages of screening a 55 year-old man with a PSA test for prostate cancer?
• Sensitivity and specificity is poor - many false positives and some false negatives.
PSA is elevated in a number of benign conditions. This can lead to patient distress and unnecessary further investigations.
Over diagnosis and over testing and over treatment that has many side effects.
Thus PSA has a significant harm to benefit ratio.
- What are the classical symptoms and signs of renal cell carcinoma?
The classical triad of RCC includes:
- flank pain
- hematuria- observed only with tumor invasion of the collecting system. When severe, the bleeding can cause clots and “colicky” discomfort.
- palpable abdominal renal mass
The classic triad occurs in at most 9% pts and when present strongly suggests locally advanced disease.
The diagnosis is commonly made as an incidental finding on USS or CT or on further investigation after discovering microscopic
haematuria incidentally.
EXTRA=
Other symptoms can include paraneoplastic symptoms such as:
- anemia= due to chronicity of the disease
- erythrocytosis= ectopic production of EPO
- hypercalcemia= Increased production of prostaglandins that promote bone resorption, lytic bone metastases, overproduction of Parathyroid hormone-related protein due to cancer.
- A 60 year-old woman attends ED with a three week history of blood in the urine, including some clots. She has had an intermittent urinary stream in the past 24 hours, and is complaining of suprapubic pain when voiding. She has had frequency and urgency of voiding for one month. There is nothing remarkable in the rest of her history. On examination, she is pale, pulse of 100 bpm, BP 105/70 mmHg, her Hb is 8.2 g/dl with a pattern consistent with iron deficiency, the rest of her blood work is normal.
What is the important diagnosis to exclude, what factors are relevant in taking a history in this case?
The most important diagnosis to exclude is urological malignancy which can include:
- transitional cell carcinoma of the bladder
- renal cell carcinoma
Factors that are relevant in taking a history of this case include:
- the timeline of her presentation
- the colour of her urine and any other abnormalities in her urine- e.g. stones
- malignancy red flags such as bone pain, unexplanined fatigue, weight loss and night sweats
- whether she has flank pain, fevers or other lower urinary tract symptoms
- any exacerbating or triggering events- trauma/surgery
- Risk factors such as smoking, pelvic irradiation, occupational exposure to chemicals particularly benzenes and amines and family history of renal disease.
-gynaecological and sexual history
AND
-Past medical and surgical history - medications (aspirin, warfarin, NSAIDs, cytotoxic agents) and treatments
- You are an ED intern. A 40 year-old woman presents to the ED. She has a fever of 39.4°C, Blood pressure of 90/40 mmHg, pulse 120 regular, respiratory rate of 24, she is drowsy and confused when answering questions. She initially complained of left sided abdominal pain, and the pain came in waves 3 - 10 minutes apart, with an urge to pass urine. She has a history of left sided renal calculi, and 48 hours before presentation she had lithotripsy (ESWL) to her left sided kidney stone.
- What is the likely diagnosis?
- What will you do?
- Most likely diagnosis is urosepsis as a complication of urolithiasis.
The ureteric colic is most likely a complication of the Extracorporeal shock wave lithotripsy causing Steinstrasse - The first thing I would do is a primary survey and stabilise the pt.
I would then focus on the Sepsis SIX:
- give supplemental O2 to keep O2 sats above 94%
- put in 2 large bore canulas and give IV crystalloids and take bloods for blood cultures, FBC, UEC and VBG for lactate
- give analgesia= opioid or diclofenac
- give empirical antibiotics= Gentamicin and Ampicilin
- I’d measure urine output- I’d consider a urinary catheter and perform a urinalysis and urine MCS
An Urgent urological consult is essential for decompression
- A 30 year-old man 234. presents with a lump in the right testicle. It is painless, he noticed it a few weeks ago, due to discomfort running. He is a smoker and has a persistent cough. On examination, there is a 3cm distinct lump within the right testis, it is clearly different from the rest of the testis and epididymis, it is not tender and does not transilluminate. Abdominal and chest exam are normal.
What is the likely diagnosis, what are the necessary investigations?
- The most likely diagnosis is testicular cancer (most likely germ cell seminoma) as it is a painless mass attached to the testis and does not transluminate.
- After the history and clinical examination.
The diagnostic evaluation of this pt with suspected testicular cancer includes:
- scrotal ultrasound= Differentiate fluid filled cyst from solid mass
Fx: Hypoechoic mass, irregular borders, within the testis - followed by CT of abdo, pelvis and chest
- measurement of serum tumor markers=
alpha-fetoprotein (AFP), beta-HCG and LDH - radical inguinal orchiectomy (entire spermatic cord is removed as well as the testicle itself), and in some cases, retroperitoneal lymph node dissection (RPLND).
The results are used to determine the histologic type and extent of disease, and to guide therapy. Testicular biopsy is not performed as part of the evaluation due to concern that it may result in tumor seeding into the scrotal sac or metastatic spread of tumor into the inguinal nodes.
- A 30 year-old man presents with a lump in the right testicle. It is painless, he noticed it a few weeks ago, due to discomfort running. He is a smoker and has a persistent cough. On examination, there is a 3cm distinct lump within the right testis, it is clearly different from the rest of the testis and epididymis, it is not tender and does not transilluminate. Abdominal and chest exam are normal.
- What is the likely diagnosis? 2. How do you differentiate between different scrotal lumps on clinical examination?
- Most likely testicular cancer.
- Differentiation between scrotal lumps can be done systematically on clinical examination based on features such as:
- location
- attachment to nearby structures
- whether the mass is transilluminable
- and whether it is tender.
- What are the indications for a person to be put on the kidney transplant waiting list?
indications for a person to be put on the kidney transplant waiting list include:
- End stage renal disease requiring dialysis – eGFR <30
- Anticipated low perioperative mortality
- Reasonable post-operative graft survival – likelihood transplant will work for >5yrs needs to be >80%
- No absolute CI
Absolute contra-indications include:
- Active malignancy
- Active infection (HIV, HBV/HVC)
- Substance abuse
- Uncontrolled psychiatric disease
- Documented and on-going non-compliance
- Life expectancy <5 years
- Significant comorbidities such as PVD, HF, COPD, cirrhosis, CVD
- What tissue matching tests are required when the transplant service is deciding which patient on the waiting list gets a donor organ when one becomes available?
The tissue matching tests required are HLA tissue typing, ABO blood group typing and serum cross matching.
Serum cross-match is when donor cells are mixed with patient serum to test for antibodies against donor cells.
Positive cross match means that the donor cells are destroyed by host antibodies and would result in immediate rejection of transplanted organ.
•Human Leukocyte Antigen (HLA) typing.
- HLA is the human version of the MHC, a surface protein that has the ability to display foreign antigens for detection by immune cells
- HLA (MHC) Class I – present on all nucleated cells – groups A, B, C
- HLA (MHC) Class II – present on APCs (B-cells, dendritic cells and macrophages) – groups DR, DP, DQ
- HLA molecules exhibit extreme polymorphism
and matching involves trying to match as many of the HLA loci as possible between donor and recipient - HLA-A, HLA-B, and HLA-DR are the most important loci for transplantation
- This is a CT scan of a patient with a congenital renal abnormality.
Q1. Can you identify the problem?
Q2. What does this situation predispose to?
Q3. How might the patient present?
- Ddx:
- pelvic kidney (explained in 293)
- horseshoe kidney
- polycystic kidney disease - FOR POLYCYSTIC KIDNEY the disease predisposes to:
- pyelonephritis
- nephrolithiasis
- RCC
- renal insufficiency and end stage renal disease
- cardiac diseases (e.g. mitral insufficiency- valve doesnt close properly=mitral regurg)
FOR HORSESHOE KIDNEY the disease predisposes to:
- ureteropelvic junction (UPJ) obstruction (35% of pts)= obstruction due to the high insertion of the ureter into the renal pelvis. The crossing of the ureter over the isthmus may also contribute to obstruction.
This obstruction then predisposes to urinary stasis, renal stone disease and infection.
3.
presentation of PCKD:
- haematuria
- flank pain= infection/nephrolithiasis
- HTN
- renal failure (oliguria/anuria AND uraemia= high urea and nitrogenous products in blood)
presentation of horseshoe kidney disease:
- 1/3 of patients with a horseshoe kidney remain asymptomatic, and the horseshoe kidney is an incidental finding during radiological examination
Symptoms, when present, are usually due to obstruction, stones, or infection.
- This CT scan shows an abnormally positioned kidney.
Q1. Where is the kidney located?
Q2. What are the consequences of this abnormality?
Q3. How might the significance of this vary between men and women?
This is a case of ectopic kidney.
Renal ectopy occurs when the kidney does not normally ascend to the retroperitoneal renal fossa (L2).
Ectopic kidneys that do not ascend above the pelvic brim are commonly called pelvic kidneys. Rarely, the ectopic kidney is found in the thorax.
- In this case= Kidney is most likely in or near pelvis.
- Patients can be asymptomatic. However abnormal urine flow (like vesicoureteral reflux) and the placement of the ectopic kidney can lead to various problems.
• Renal calculi (forms due to urinary stasis)
• Hydronephrosis (kidney swelling due to impeded urinary flow) due to pelviureteric obstruction
• Recurrent UTI due to defective anti-reflux mechanism
- if kidney is in pelvis also more susceptible to trauma
- kidney damage
- In women renal abnormalities are associated with gynaecological abnormalities. An ectopic kidney can lead to obstructed labour.
The other significance is in the variation of an ectopic ureter if one is present.
In men the ureter will always enter the urethra proximal to the external urethral sphincter whereas in women an ectopic ureter may enter distal to the external urethral sphincter and therefore persistent urinary incontinence can occur.
Other genetic defects can coexist and this can present differently in men and women.
In men you can get: o Cryptorchidism (undescended testis) o Hypospadias (urethral orifice on shaft of the penis)
In women you can get:
- uterovaginal atresia (failure to develop)
