RENAL MEDICINE H+E:
How often? How much – polyuria ® oliguria (<400mL)® anuria (<40mL) ? [possible UTI]
F requency • Small void – BPH?
• Clear urine = Renal failure?
U rgency • Sudden/gradual urge? è (stress, urge, overflow incontinence)
N octuria Excessive urination at night è benign prostatic hyperplasia (BPH)
Any pain when urinating? è Flank / Back Pain? è Does it radiate? [renal colic – STONES?]
• Infection?
D ysuria
• Pain syndrome?
• Storage/trigonal/ureteric pathology?
W eak stream Does it flow out slowly? è (hesitancy)
I ntermittency Flow that stops and starts
S training/Strangury “Do you need to strain to urinate?” (prostate issue) | Or strangury = bloody urine + dysuria
E mptying incomplete Dribbling è Pis-en-deux ® double-voiding (incomplete bladder emptying)
• Smell & Colour (Heamaturia, pale, dark yellow),
Quality • Consistency (foamy = proteinemia | microscopic deposits in urine = casts )
1. History of (e.g. RBC casts/clumps = haemorrhage , WBC casts = infection/inflammation)
presenting Fever • Night Sweats [clear differential that it is NOT CKD] è UTI or stones
complaint
• Protective sex | Libido | Vaginal/Penile Discharge | Genital rash
Common
[FUNDWISE-QFS] • Infertility | Urethral discharge (STIs)
[PORN HAWCS] • Pre-ejaculation |Erectile dysfunction (Full Erection) è diabetes or HF
Men
• Retrograde ejaculation
Sexual Health • # of Pregnancies | Orgasm (MS?, spinal cord disease)
• LAST menses cycle (regularity – 28-35 days)
• Oligomenorrhea (regular menses)
Women
• Amenorrhea (primary = menopause or ovarian failure, Oral contraceptives)
• Menorrhagia (heavy menstrual flow)
• Dysmenorrhea (pain with menstruation)
General symptom screen especially for CKD (eGFR < 60 mL/min/1.73m2):
• Hiccups | Anorexia (reduced appetite + metallic taste)
• Pruritus
(accumulation of ureamic toxins)
• Oliguria (< 400mL = LATE stage CKD)
• Weight gain/loss (Unexplained)
• REST è insomnia | Fatigue/lethargy
• Confusion
Malaise (discomfort)
• Swelling/Oedema (weight gain) è extremity swelling, pleural
• Nausea & Vomiting
effusions, pulmonary oedema èexertional SOB
(accumulation of ureamic toxins)
• polydipsia (excessive thirst)
Kidneys Ureter Bladder Prostate Urethra/Gynae/Teste
• Sepsis • Sepsis • Sepsis • Sepsis • Sepsis
• Loin-groin pain • Loin-groin pain • Cystitis [FUND] • Cystitis [FUND] • Obstruction [WISE]
2. Organ Focus
• Heamaturia • Heamaturia • Incontinence • Incontinence • Mass
(kidneys, ureter,
bladder, genitals, • Heamaturia • Obstruction [WISE] • Burning/pain at tip
urethra) • Vitals, febrile • Vitals, febrile • Vitals, febrile • Vitals, febrile • Vitals, febrile
• Ballotable • +ve dipstick • Palpate Bladder • Percuss Bladder • Pelvic exam (Females)
kidney • +ve dipstick • DRE (size, tender) • Testicular mass
• +ve dipstick
• Conditions = Previous UTI | diabetes (gestational, obese) è hypoglycemic episodes | HT | Gout |Enuresis
3. Past MHx • Medications:
[CHOMV STAVE] 1. oral hypoglycemics | PDE5i (Viagra) = erectile dysfunction
“compliance about 2. Nephrotoxins: IV contrasts (lithium), NSAIDs (aspirin) | Alpha-blockers (prostatic enlargement)
medication?” 3. Diuretics è adds to nocturia / incontinence / stones | Antibiotics (UTI prophylaxis + strep infections)
4. ACEi/ARBs è elevated creatinine
• Home life/accommodation + family support (esp. prostate cancer predisposes children)
• Independence: mobility care/needs [CKD patients have social problems – How are you coping?]
4. Social Hx
• Lifestyle + Hobbies è DIET + EXERCISE (Esp. dietician advice)
[SHIELDOM]
• Alcohol (CAGE questions) | Smoking (pack years) + when did they quit |
• Drugs (opioids, benzodiazepines, hallucinogens, cannabinoids – how long, how administered)
5. Family Hx • FHx of renal disease: Autosomal dominant polycystic kidney disease or glomerulonphritidies (e.g. IgA neuropathy)
“important for young child • Family Hx of CV risk factors (e.g. diabetes and HT)
with diabetes” • Family Hx of deafness and renal impairment (Alport’s syndrome è inherited nephritis)
Biochemical examination [DIPSTICK]
Urinalysis Indication Interpretation
Colour Heamaturia
Turbidity Proteinuria or bacteria
pH acidity of urine
↓pH in systemic acidosis = More suggestive of HC
infection
amount of solute
Specific gravity ↓ in DI, polydipsia
dissolved in
Blood RBC in urine Infection, inflammation, cancer, obstruction?
Protein level of protein in the urine ↑ nephrotic syndrome
• High sensitivity ATN CKD
Leukocyte enzyme produced by • low specificity for infection as can be
esterase neutrophils due to STI, renal calculi, IDC, recent
surgery, chemo
• Higher specificity (more likely to be MICROSCOPIC examination of Urine sediments (RBC, WBC, bacteria, casts)
breakdown products
infection) Feature Indication
Nitrites caused by
Gram -ve organisms • low sensitivity as some bacteria do not RBC haematuria, haemoglobinuria or myoglobinuria
produce nitrites confirmed by + positive leukocyte esterase)
WBC
breakdown product of UTI or urinary tract inflammation
Ketones ↑ starvation / ↑DKA
fatty acid metabolism • cylindrical structures formed in the lumen of renal
Glucose ↑ hyperglycaemia poorly controlled diabetes tubules and collecting ducts by precipitation of
Casts
mucoproteins secreted by cells in the kidney
Bilirubin ↑ conjugated bilirubin ↑ biliary tract obstruction • WAXY CASTS = CKD
Urobilinogen ↑ bilirubin turnover ↑haemolytic anaemia
, Urological Key Features
Diseases = Possible causes [VITAMINS D]
• V= vascular issues Failure Type Description
• I = Infection/inflammation
rapid severe loss in renal function è waste
• T = traumatic causes • Acute (AKI)
accumulation + oliguria
• A = auto-immune conditions
• M = malignant tumour (or benign) • Chronic Persistent > 3 months
• I = iatrogenic (caused by physician/surgery)
• N/M = Neoplasms or metabolic abnormality • Acute on Worsening of kidney function when patient has CKD
• S = Stones + strictures/stenosis +cysts chronic
• D = Drugs
Urine Issue
• Urological: cystitis, urethritis, pyelonephritis, BPH
Dysuria
• Other: anxiety, prostatitis, pregnancy, bladder or lower urethral calculi, drugs (e.g. diuretics)
• Endocrine: (T2DM, diabetes insipidus, cushings)
Polyuria
• Urological: CKD, UTI,
Oliguria (<400mL/day)/ • Late stage CKD, urethral stricture, BPH, UTI (+ dysuria), bladder neck obstruction (i.e. tumour, calculi)
Anuria (<50mL/day) • Other: Phimosis, MS, SCI, anticholinergic drugs, constipation (common), SIADH
Colour of urine Underlying cause
• overhydration, recent colourless excessive beer consumption,
Very pale/colourless
• diabetes insipidus,* post-obstructive diuresis
• Concentrated urine (e.g. dehydration), Bilirubin
Yellow-orange
• Drugs: Tetracycline, anthracene, sulfasalazine, riboflavin, rifampacin
Brown • Brown Bilirubin, Nitrofurantoin, phenothiazines; chloroquine, senna, rhubarb (yellow to brown or red)
• Beetroot consumption
Pink
• Drugs” Phenindione, phenolphthalein (laxatives),
• bladder transitional cell carcinoma (painless hamaturia)
• renal cell carcinoma | urethral trauma (e.g. catheter) | UTI | Urethitis
Red / heamaturia
• Other Urological: glomerulonephritis, PKD, BPH, urinary tract TB
• Miscellaneous: coagulopathy, sickle cell, IE, menstruation, rhabdomyolysis
Green • Methylene blue, triamterene, myoglobinuria when mild
• Severe haemoglobinuria
Black • Melanoma, ochronosis; porphyrins, alkaptonuria (red to black on standing)
• Drugs: Methyldopa, metronidazole, unipenem
White/milky • Chyluria (Pus, chyle (lymphatic fluid) or blood can cause a more turbid appearance)
• Phosphate or urate deposits can occur normally and produce white (phosphate) or pink (urate) cloudiness
Cloudiness
• Fainter cloudiness may be due to bacteria
Smell of urine Underlying cause
mild ammoniacal smell • normal
fishy smell • urinary tract infection (UTI)
Asparagus smell • antibiotics
Types Of Incontinence [cannot hold urine]
Stress incontinence Urge Incontinence Overflow incontinence INNERVATION TO URINATE
(outlet incompetence) (detrusor overactivity) • PSNS è ACh è detrusor relax [PROPULSION]
Inability of sphincters to hold Sudden contraction of detrusor muscle Underactive bladder • SNS è NA è sphincter contracts [STORAGE]
urine = Involuntary urine when bladder only partially filled ® causing urine to leak out • Somatic pudendal è external urethral sphincter
Issue leakage (esp. on ↑intra-abdo [large volume – sudden urge] (incomplete emptying) (voluntary control)
pressure = cough /sneeze / Ø Dry = reaches toilet in time [low volume]
exercise) Ø Wet = cannot make to toilet
1) Weak abdo muscles 1) UTI Ø MAIN = Chronic
(multipregnancy) 2) Overactive bladder syndrome urinary retention
2) +++ intra-abdo pressure > 3) Bladder Stone/clot/tumour (e.g. opioid usage)
closing pressure of 4) Neuro = T2DM, SCI – stroke, Ø Obstruction =
urethral sphincter = Alzheimer, PD, Urethral stricture,
RF obesity, heavy lifting, Stones, UTI
chronic cough Key notes: Ø Weak bladder
3) Sphincter tone failure = 5) Triggers = Advanced age, muscles = NMD,
childbirth trauma Smoking diabetic cystopathy
4) Loss of urethral support 6) URODYNAMIC studies needed
= post-meno E2 def.
Ø Prolapse Sx = fullness, dragging, back ache Basic Investigations
Ø Sexual Sx = dyspareunia Ø UA MSU + M/C/S
Ø Pelvic pain = bladder, pudendal neuralgia (worse on sitting) ® if Ø Pelvic USS (post and
relieved with pudendal block (= NANTES) pre-void residue)
Exam + Ix
Ø +ve Cough/stress test = stress leak Ø Uroflowmetry
Ø DRE = assess anal sphincter tone + rectocele Ø Intake-void diary (3-5
Ø Neuro exam (L1-S4) = perineum sensation + sacral reflex (anal days)
wink)
Ø Reduce BMI < 25 Ø ↓↓fluid intake (esp. ↓caffeine, Ø Timed voiding
o NEAT regime ↓EtOH, soda) (bladder retraining)
Ø PT = Kegel exercise (If no Ø Timed voiding (bladder
Conservative hip #) especially post- retraining)
pregnancy for prevention Ø Manage constipation IMPORTANT DIFFERENTIAL FOR “LEAKY URINE”
Ø Vaginal pessary (1st line for Ø UTI – “burning, stinging sensation + frequency”
prolapses) Ø PROLAPSE - fullness
Ø + metformin (if DM) Ø Oxybutynin (anti-chol -M3 to Ø Local E2 ® manage Ø HERNIA – reducible (DDx: incarcerated)
Ø Topical estrogen ↓ACh – ANTI-SLUDGE) post-meno atrophy Ø NEURO – MS, DM, Cauda Equina
Ø Mirabegron (B3 agonist – less *Flomax (tamsulosin) in Transient incontinence [DIAPPERS]
Medical
A/E) men for both urge and Ø Delirium,
Ø Duloxetine = SNRI ® ↑ contract overflow Ø infection,
internal urethral sphincter Ø atrophic urethritis,
Ø Mid-urethral sling - Ø Botulinum toxin ® blocks ACH Ø IDC (self- Ø pharm, psych,
tension free vaginal tape release ® injected directly into catheterise) Ø XS urine (caffeine, EtOH),
(TVT) bladder via cystoscopy (Pt must Ø Continuous bladder Ø restricted mobility,
Ø Colposuspensions self-catheterize as botox can lead drain
Ø stool incontinence
(laparscopically) to urinary retention)
Surgical Other types of incontinence)
*Rarely used = urethral injections Ø Neuromodulation ® posterior
(bulking agents e.g. silicon) Ø Mixed
tibial or sacral nerve ® inhibit
Ø True/continuous (? Fistula, ectopic ureter)
reflex contraction of bladder
Ø Nocturnal uresis
Ø Situations (coital/giggle)
