Adult Renal Part 1

Dysuria

• Dysuria involves the subjective experience of pain or a burning sensation during urination.
• It includes frequency, urgency, hesitation, and strangury.
• Can stem from medical conditions, certain medications, or lower urinary system infections.
• Lower urinary system infections are the most common cause

Dysuria: Differential Diagnosis

• It is often linked to bladder problems and rarely renal disease.
• Prostate, bladder, and urethra inflammatory lesions can cause Dysuria.
• Bladder tumors, chronic renal failure, nephrolithiasis, and upper urinary system diseases can also contribute.
• Issues outside the renal system, such as STIs, vaginitis, and prostatitis, may be factors.
• In women, vaginal discharge or irritation should be taken into account.
• Symptoms can point to other diagnoses such as urethral strictures, prolapsed uterus, pelvic peritonitis, or cancer of the cervix or prostate.

Dysuria: Testing

• Urinalysis is the easiest, most noninvasive, and economical way to identify UTIs and other renal problems.
• Begin treatment after the associated condition has been identified.
• Dipstick testing can be done, along with a culture.

Hematuria

• Hematuria is the presence of blood in the urine.
• Bacterial infections are a common cause and presence of bacteria on urinalysis suggests an infectious cause.
• Acute cystitis or urethritis can lead to gross hematuria.
• Proteinuria and hematuria might suggest glomerular or interstitial nephritis, especially with a history of sore throat or skin infection.
• Hematuria can either be visible (gross hematuria) or occult (microscopic hematuria).
• Microscopic hematuria is characterized by more than 3 RBCs per high-power microscopic field (hpf).
• Emergency Department referral is required for substantial frank hematuria, severe flank pain indicative of renal calculi, unstable vital signs, obstruction signs, or acute renal failure.
• Transient hematuria occurring on one occasion may be caused by a new onset of dark reddish-brown urine, edema, proteinuria, fatigue, and decreased urine output after recent strep throat, scarlet fever, or impetigo, suggesting poststreptococcal glomerulonephritis.
• Persistent hematuria occurs on two or more consecutive occasions
• Both transient and persistent can be a sign of a serious disease

Hematuria Details

• Urine color can range from light pink to dark red, or appear "smoky".
• Color depends on several factors: amount of blood present, timing of hematuria, dietary intake, meds, dilution, and pH.
• Important historical factors include renal calculi, UTIs, recent illness, nasal secretions containing blood, medications like Rifampin or phenytoin, STD, travel to schistosomiasis-endemic areas, and consumption of certain foods/dyes.
• Assessment should consider a patient's age, gender, and activity level.
• Hematuria is seen up to 13% in long distance runners.
• Hematuria with pyuria suggests infectious process.
• Hematuria with colicky flank pain suggests pain in ureter
• If bleeding occurs at the beginning or end of micturition, the source could come from a prostatic or urethral cause.

Hematuria: Clinical Presentation and Diagnostic Testing

• Inquire about strenuous exercise, streptococcal infection, nephrolithiasis, family history, and recent travel.
• A physical exam could reveal:
  • Costovertebral angle tenderness, potentially indicating pyelonephritis.
  • Abdominal mass: neoplasm, polycystic kidney disease.
  • Suprapubic tenderness: bladder etiology.
  • Urethral discharge: urethritis.
  • Enlarged and/or tender prostate: BPH, prostatitis.
  • A prostate exam should be performed on men, and uncircumcised men should have foreskin retracted to assess.
  • Women: Vaginal and urethral exams.
• Urinalysis should be repeated to assess hematuria after treatment.
• If RBCs are present, it indicates hematuria that is originating from the renal parenchyma, an intact and uniform RBC is present
• Presence of intact RBCs, WBC and bacteria (nitrates) suggests hematuria is resulting from UTI, and need a urine C&S. This should be repeated in 6 weeks after antibiotic therapy completion to ensure resolution.
• If there is significant proteinuria (> 1g/24hr), dysmorphic RBCs, or coca cola colored urine, it is further evidence of renal source
• Positive tests detect erythrocytes, but positive test can also suggest myoglobinuria or hemoglobinuria.
• If the dipstick heme test is positive, the urine should be tested for myoglobinuria and hemoglobinuria.
• Gross hematuria can appear pink, red, brown, or show blood clots that may require performing imaging along with cystoscopy
• Testing for suspected renal origin includes:
  • Antinuclear antibodies (ANAs)/Immunoglobulins
  • Chemistry panel with creatinine clearance, BUN
  • CBC with platelets
  • ASO (streptolysin O) titer, VDRL
• Malignancy should be tested for with cytology and referral to nephron if older than 50, male, smoker, and has gross hematuria.
• A urine culture and sensitivity is needed
  • Noncontrast CT to rule out urolithiasis should be preformed if there is no growth with culture but is painful
  • If painless, do urine cytology x3 and urine c/s, ultrasound of bladder/kidneys for renal mass , and 24-hour urine collection if RBC casts or proteinuria is present.

Hematuria: Further Testing and Diagnosis

• Phase-contrast microscopy helps to examine the morphology of RBCs.
• Tests include intravenous pyelogram (IVP) or renal ultrasound, and CT scans.
• A CT scan can rule out urolithiasis if hematuria is painful and urine culture is negative, a CT for kidneys should be done if there is a renal mass.
• PT, PTT, PPD, ESR, ANA, ASO, and urinalysis for cytology.
• Cystoscopy can evaluate upper urinary tract if hematuria is painless.
• A diagnosis requires a drug, dietary, and menstrual history.
• Drugs that cause hematuria: beta-lactam antibiotics, sulfonamides, NSAIDs, rifampin, Cipro, Zyloprim, Tagamet, Dilantin, and anticoagulants.
• Dietary substances that can cause bladder irritation: caffeine, spices, chocolate, alcohol, citrus fruits, and soy sauce.

Hematuria: Causes

• Hematuria is grouped according to the anatomical site of the blood source.
• Urologic causes can be tumors, calculi, infections.
• Glomerular hematuria is associated with significant proteinuria, erythrocyte casts, and dysmorphic RBC.
• Berger disease, Alport syndrome, and thin basement membrane disease is associated with Glomerular hematuria
• Nonglomerulat hematuria is associated with significant proteinuria but not erythrocyte casts or dysmorphic RBC.
• Isolated hematuria is bleeding anywhere from the renal pelvis to the urethra.
• Injury to the nephron shows as RBC casts
• Acute cystitis and urethritis lead to gross hematuria.
• Proteinuria and hematuria suggest glomerular or interstitial nephritis.
• Colicky, flank pain indicates ureteral stones.

Proteinuria

• Urinary protein excretion of more than 150 mg/day (10-20 mg/dL) is the hallmark of renal disease.
• Microalbuminuria: excretion of 30-150 mg of protein daily and indicates early renal disease (diabetes).
• Proteinuria is indicates a renal pathology of glomerular origin, and chronic kidney damage if persistent.
• Functional proteinuria may be caused by conditions such as illness, emotional stress, or exercise.
• Other causes are overproduction of filterable plasma proteins, and being asymptomatic.
• Intermittent proteinuria may have no symptoms, and is discovered through urine dipstick testing.
• 24-hour urine collection is most accurate way to quantify protein in urine.
• Urgent referral if there is new onset proteinuria in pregnant woman in order to exclude eclampsia
• Proteinuria before 20 weeks gestation may indicate glomerulonephritis.
• Preeclampsia may be indicated by proteinuria after 20 weeks gestation

Proteinuria: Causes and Testing

• Transient/temporary proteinuria can be from benign, functional or orthostatic proteinuria; exercise; environmental conditions; fever; acute illness; CHF; seizures.
• If there is exercise or fever, further testing is not needed
• Persistent +1 dipstick protein (30 mg/dL) should be tested twice in a 3 month period.
• Pathologic signs can be drug induced, genetic, immune, infectious, metabolic, or vascular disease.
• When found in low-risk patients, testing should be done for Bence Jones protein to associated with multiple myeloma.
• Glomerular cause is likely if there is more than 2g of protein for every 24 hours.
• Leading cause of ESRD is Diabetes, and microalbuminuria is the first sign of deteriorating renal function.
• A routine dipstick and 24-hour urine test can be done for testing.
• A 1+ or greater result should be investigated.
• If apparent cause like diabetes or eclampsia does not exist, spot urinary protein/creatinine ratio or 24-hour urine testing is recommended.
• Urine protein greater than 150 mg in 24 hours is significant
• DO urine protein IEP if abnormal proteins are found
• A serum protein electrophoresis should be done to test for multiple myeloma via Bence Jones proteins
• Test A1C and Lipid profile
• Test urine culture and it's sensitivity
• IF persistent proteinuria is expected; a 24-hour urine test of protein and creatine clearance should be done to test protein excretion and protein/creatinine ratio
• 3.0 to 3.5 g/day: indicative of nephrotic syndrome, and refer to nephrologist (potentially diabetes).
• Do ANA to r/o SLE, cANCA to r/o granulomatosis with polyangiitis, HCV, HIV, Hep B antigen to r/o viral etiology, Anti-GB to r/o Goodpasture syndrome, C3/C4 to r/o cryoglobulinemia, r/o diabetic nephropathy.

Proteinuria: Management

• Goal: protein excretion rates (measured with 24-hour urine test for total protein) of 1g/day or less. Rates higher than this have been shown to have increased cardiovascular disease.
• Angiotensin-converting enzyme (ACE) and (ARB) medications can reduce proteinuria by decreasing interglomerular pressure, and should be discontinued if they are the cause
• Treat hyperlipidemia, diabetes, or hypertension aggressively.
• May require a sodium and protein restricted diet
• manage patients with chronic renal failure aggressively to prevent ESRD
• Patients with diabetes: use SGLT-2 inhibitors and glucagon like peptide -1 receptor antagonists to reduce levels of albuminuria and control blood sugar.
• Nephrology consult if necessary.

Urinary Incontinence (UI)

• UI is the involuntary loss of urine from the bladder, and is abnormal at any age regardless of gender.
• Common in women over the age of 50.
• Most often related to bladder or pelvic floor dysfunction due to muscles that are affected by pregnancy, childbirth, or menopause.
• Risks include obesity, aging, delivery, smoking, constipation.
• UI is common in older men due to enlarged prostates, or radiation/surgery from prostate cancer
• Causes for transient UI include delirium, infections or systemic illness, and medications.
• Occurrences for persistent UI is categorized as stress (sneezing/coughing that increases intraabdominal pressure) , urge (physiologic changes), outflow (BOO and incomplete emptying of bladder), and other functional issues like dementia

UI: Pathophysiology, Clinical Presentation

• Age related changes that can cause UI:
  • Decreased bladder capacity
  • Increased postvoid residual urine volume
  • Increased disinhibition of bladder contractions
  • Increased nocturnal sodium and fluid excretion.
  • Benign prostatic hyperplasia leads to Urinary overflow
• Weak pelvic muscle walls in women post-menopausal can cause UI
• Competence of internal and external sphincters decreases do to Estrogen deficiency from atrophy of urethral mucosal epithelium.
• Check medical and physical history to determine the type since they all are similar.
• Assessment include symptoms related to incontinence, bowel habits, medications, surgical and GU, pelvic trauma,neurologic issues. -Psych exam: assess self esteem, social withdrawal, sexual dysfunction secondary to embarrassment; the possibility of dehydration should be kept in mind (from patients possibly limiting fluid intake).
  • Abdominal exam: constipation, fecal impaction, masses, distended bladder
  • Pelvic exam: Assess strength or any problems related to structures
  • Skin: look for atrophic vaginitis, or foreskin abnormalities
  • Congestive heart failure: determine fluid or catheterization levels
• Evaluate mental status and mobility impairment, since they contribute to functional incontinence.
• In men: check for phimosis, or rectal masses
• In women: check urethra mobility, look for movement, assess for loss with exercise

UI: Diagnostic Testing

• Urinalysis can rule out hematuria, pyuria, glucosuria and proteinuria.
  • Hematuria of over 3 RBC requires a negative culture for cytologic study, upper tract imaging, and bladder cystoscopy
• Serum electrolytes, BUN, creatinine are tested if compromised renal function is suspected, especially w/ incontinence
• Test glucose and calcium if polyuria is suspected
• Do a catheterization or bladder scan to check for completion of bladder emptying
• Patients need a PVR check if they have voiding symptoms, pelvic organ prolapse, or bladder overdistention.
• For normal, PVR is < 30
• Urodynamic testing and cytometry can be done, along with cystometrogram and video urodynamics
• Visualize using ultrasound to check structure functions in pelvis, rectum, or kidneys

UI: Differential Diagnosis

• Symptoms of urge incontinence come from hyperactive or non compliant bladder
  • Related to infections or kidney stones
  • Pelvic floor can be laxity, related to bladder outlet, or sphincter weakness
• Stress incontinence: happens with sneezing or coughing
• Chronic retention/overflow: prostate or stricture
• Especially spinal cord injuries

Stress Incontinence: Management

• Involuntary urine loss happens with coughing, sneezing, or laughing.
• Therapies: Timed/voiding with diary, weight loss, pelvic exercises, placements, manage stool
• Kegel with biofeedback treatment: Initial with Combo of pelvic floor exercises by digital palpation will work most
  • Avoid descent of urethra, will increase urethral bulk
  • Contractions should be held for 5 seconds and repeat for 6 months
  • Weight loss will help
  • Electrical stimulation methods
  • Medications is helpful for younger:
  • Alpha adrenergic agonists (pseudoephedrine) - Tca (imipramine) PO 1- 3x a day for 10 to 20 mg
  • Eliminate diuretics
  • As well as surgery if needed

Urge Incontinence: Management

• Urge Incontinence - Inability to delay voiding from involuntary leakage of urine.
• Behavioral Methods - bowel management , Keagel exercises, diary, double voiding.

Managing Urinary Incontinence: Fluid, Irritants, and Medication

• Bladder Training: resist sense of urgency and voiding, required to void a schedule, requires them to postpone voiding every 2 - 3 hours
  • Bladder should be emptied and delayed when needing to urge more frequently
• Prompt scheduled voiding by every 2 - 4 hours
• Bladder Irritants: increase urgency - spicy, acidic foods,and caffeine
• Manage Fluid: intake by 48-64 oz daily
• Medications: tricyclic antidepressants - topical estrogen, antimicrobial agents.
• Anticholinergics should be avoided in older adults; except for Mirabegron

Overflow Incontinence and Other Incontinence

• Leakage of small amounts of urine when bladder pressures increase caused by overdistended bladder by pt not feeling void
• Atonic Muscle, Diabetes, or with Medications
• Intermittent catheterization and consider surgery
• Consider scheduled toileting
• Prescribing alpha blocker meds

Functional Incontinence: Causes and Management

• Functional incontinence - Is caused by factors outside of the lower urinary tract. Delirium, urinary infection, excess urinary output, or stool impaction
• Physical or Occupational Therapy to manage these types of issues
• Bladder programming, habit training, and surgery.

Managing Functional Incontinence and OAB

• Educations on scheduled bladder and bowel routine
• Follow up with treatment or medication and refer patient
• Provide encouragement and support
• OAB- or Overactive Bladder is all associated with an involuntary contraction of the detrusor
  • Cause includes: neurological conditions (drugs and alcohol), also anxiety and depression in women
  • Begin treatment by: identifying women who are experiencing the problem, and treatment with antimuscarinic agents
• Block stimulation with acetyl choline using agents such as Oxybutynin and Tolteroclind to stimulate the detrusor

Lower UTI

Occurs when the condition is invaded by bacteria: bladder, urethra, bladder wall, and prostate glands.

• Characterized with the infections
• Chronic Infections obstruction on bacteria and more strains and can be resistant Other cases are complicated infections
• Accompanied in Structural problems
• More prevalent in people who are sexually active
• The Most common bacterial cause is E. coli
• structural abnormality can be found

Diagnosing and Addressing Lower UTI

• Diagnosing for UTI the dipstick has higher rate in detection and the urinalysis is the most important study show show leuks grater then 10. Most elevated and also RBCs in the sediments.
• Most diagnosis are confirmed by the presence of signs and symptoms
• Males are acute to the symptoms
• Urinary Growth contamination is typically indicative of contamination.
• Urinary culture in conjugation can be great, or used separately from a dipstick. Urology for persistents/referrals and for targeted treatment
• If uncomplicated can be ,managed
• Outpatient care with oral antibiotics
• More Fluid and less oxalate foods is great to take

Pyelonephritis

• Is an upper UTI, which causes infection in the kidney

• Cause is ascending and may be unilateral or bilateral

• Infection in the kidney within the renal pelvis,tubules, or tissue

• The disease often includes sudden/localized , fatigue.

• Older patients w/ altered mentation can contract infections and more risks can apply

• Is marked by fever and chills; dysuria and frequency usually unilateral , following recent UTI Causation of Anatomical issues and previous UITS Causation Can be Stress - trauma during pregnancy, or in metabolic problems

• Patho: Swelling renal, as a result life and poses threats to the elderly of patients, all that is due to that presents of catheters.and infections in a renal cell area occurs this infection ascends from the urethral meatus, leading to infection when the patient is not treated and treated .

• pregnant pt: are critical must be treat because, typically caused by fecal flora that colonize and ascend

• Often follows - sudden fever, which can result of a localized fatigue and can alter mental with a infection , leading to older pt/ renal function

• Tests include renal scans for more analysis, along with lab work: WBC will be high and more tests is elevated, the urine for positive bacteria, proteina , leukocyte esterase and elevated ESR.

• Testing is needed and then also to ensure levels are appropriate, plus urine culture is often great then 100k

• Cystourethography will be recommended

Differential and Management

A specific - or with biopsy - treatment needs to be implemented when a more renal scsns

• Management - prevent permanent, with antibiotics, and the decision of Hospitalized can be considered
• treatment - 7 - 10 days , but 21 days is more severe If not - re evaluate pt fluid and cultures in the pt and test as required renal scans - then surgery needs to be delayed
• Follow up and get test run again.
• chronic renal should be and get test with nephrologist (referrals )
• Educate pt to prevent utis ,increase treatment , and take antibiotics

Incontinence types

• Overflow: prostate stricture- meds
• Stress: lax of pelvic floor, muscle weakness,
• Urge: hyperactive or kidney stores
• Functional: factors/ outside (delirium restrictions, and hygiene)