CHI335 - Genitourinary System.pdf

Urinary system CHI335 Figures and tables from: Kumar & Clark’s Clinical Medicine Davidson’s Principles & Practice of Medicine Aims & Objectives  Aim  Familiarise you with the common disorders associated with the r...

Urinary system CHI335 Figures and tables from: Kumar & Clark’s Clinical Medicine Davidson’s Principles & Practice of Medicine Aims & Objectives  Aim  Familiarise you with the common disorders associated with the renal and reproductive system  Provide the opportunity to appreciate common genitourinary disorders and recognise then in clinical practice, with a view to managing patient appropriately  Objectives  Briefly review the anatomy & physiology of the renal system  Cover common disorders and their presentation  Mention the role of laboratory investigations and patient management Introduction  Organs of the urinary system  Kidneys, ureters, urinary bladder, and urethra  Nephrons are the (microscopic) functional units of the kidneys  Functions  Excretion of many metabolic breakdown products  e.g. urea, creatinine and uric acid, drugs and toxins  Regulation of fluid and electrolyte balance  e.g. regulation of water, calcium and phosphate homeostasis  Regulation of acid–base homeostasis  Regulation of blood pressure  Vitamin D metabolism  Induces production of red blood cells Internal Structures of the Kidneys Nephrons  Bowman’s capsule  Tubules (Extend from the Bowman’s capsule)  Proximal convoluted tubule  Loop of Henle  Distal convoluted tubule  Collecting duct Structure of a Nephron Glomerulus Blood Vessels Associated with Nephrons Glomerular filtration barrier Stages of Urine Formation 1. Glomerular Filtration  Takes place in the renal corpuscles  Fluid part of blood is forced from the glomerulus into Bowman’s capsule, called glomerular filtrate Glomerular filtration depends on 3 pressures:  Glomerular blood hydrostatic pressure (filtration pressure)  Blood pressure in the glomerular capillaries (role of SNS)  Capsular hydrostatic pressure  Acts in opposition to the filtration pressure  Glomerular blood colloid-osmotic pressure  Acts in opposition to the filtration pressure Stages of Urine Formation 2. Tubular reabsorption  Glomerular filtrate flows into the proximal convoluted tubule  All the necessary substances pass through the wall of the renal tubule into the blood of the peritubular capillaries  Water reabsorption varies depending on the presence of antidiuretic hormone (ADH) 3. Tubular secretion  Substances move out of the blood in the peritubular capillaries and into the renal tubules  Secreted substances will be excreted  e.g. urea, uric acid, creatinine, various ions and some medications Tubular Reabsorption and Secretion Urine formation Urine Concentrating Mechanism Urine – Inspection  Colour  Clarity  Odour Urine Discolouration Not examinable Urine Analysis (urinalysis)  Macroscopic (visual inspection)  Color and clarity  Biochemical (e.g. urine dipstick)  pH, specific gravity, protein, glucose, ketones, nitrite, leukocyte esterase, etc.  Microscopic  Crystals, casts, epithelial cells, white and red blood cells, bacteria,… Urinalysis  Normal values  Colour: Yellow (light/pale to amber)  Clarity/turbidity: Clear  pH: 4.5-8  Specific gravity: 1.005 - 1.025  Glucose: Negative  Ketones: None Not examinable, unless otherwise advised  Nitrites: Negative  Bilirubin: Negative  Urobilirogen: Small amount (0.5-1 mg/dL)  RBCs: ≤ 1-2 RBCs/hpf (high-power field)  WBCs: ≤ 2-5 WBCs/hpf  Protein: ≤150 mg/day  Casts: 0-5 hyaline casts/lpf  Crystals: Occasionally  Bacteria, Yeast: None http://library.med.utah.edu/WebPath/TUTORIAL/URINE/URINE.html Haematuria – APPEARANCE Gross Microscopic  Urine that is visibly  Not visible to inspection discoloured by blood  Five or more RBCs/HPF  It may present as urine on 3 consecutive that is red to brown, or as specimens frank blood  Samplings must be a  Clots in urine suggests a week apart non-glomerular causes Haematuria – RBC cast  Rule out food/Meds-related red-coloured urine  Causes: Refer to DDx slide  False +ve: after vigorous exercise, menstruation RBC Cast on microscopic examination Haematuria – ORIGIN Glomerular Non-glomerular  Brown-coloured urine  Reddish or pink urine  RBC casts  Passage of blood clots  Dysmorphic (small,  Eumorphic (normal- deformed, misshapen, sized, biconcavely sometimes fragmented) shaped) erythrocytes RBCs  Possibly with concomitant proteinuria Haematuria – Gross  Stones  UTI  Trauma  Tumour  Macroscopic haematuria has a positive predictive value of 83% for bladder cancer and 22% for all urothelial tumours, rising to 41% in patients over the age of 40  Coagulopathies  Gynaecological  Iatrogenic Haematuria – DDx Proteinuria Proteinuria can be transient or persistent  Transient proteinuria  After vigorous exercise  In patients with fever  Heart failure  Patients with UTI  Persistent proteinuria warrants further assessments  It is associated with progression of kidney disease, atherosclerosis and heart problems Proteinuria  Normally urine may contain small amounts of proteins (< 150 mg/day)  This is undetectable using dipstick (microalbuminuria)  The dipstick only detects the presence of albumin and no other proteins  Positive test needs confirmation  GN, Renal tubular disease, HTN, DM, pre-eclampsia, UTI Persistent Proteinuria  Structural damage to the Glomeruli  Increase in the size and number of pores, allowing passage of more and larger molecules  Massive proteinuria (nephrotic syndrome)  Protein excretion of > 3.5 gr/day  Shown as 3+ or more on dipstick  It is an independent risk factor for end-stage renal disease in the general population, as well as in patients with chronic kidney disease Other urine tests  Culture  Drug screening  Pregnancy Urinary system Common conditions Acute tubular necrosis (ATN)  Death of a significant number of tubule epithelial cells → Alters reabsorption and secretion → Leads to kidney impairment → Acute renal failure (ARF)  Occurs as a result of  Renal ischaemia  Toxic chemical damage  Immune attack  Sepsis Acute Renal Failure (ARF)  Sudden loss of kidney function Prerenal ARF  Disruption/decrease in renal blood supply/flow (i.e. kidneys' low perfusion) causes tubular necrosis which results in ARF  Causes usually occur upstream of the kidneys  Trauma or major surgery  Heart disease with  cardiac output (e.g. a massive MI)  Hypotension of any causes  e.g. blood loss, loss of water from blood due to dehydration or burns  Stenosis of renal arteries  Occlusion of small blood vessels within the kidney  e.g. atherosclerosis and embolism Prerenal ARF  Tubule cells are very sensitive to hypoxia; however, they can regenerate if the glomerulus has survived  If the cause of ischaemia is rectified, and the patient is supported by dialysis during the period of kidney failure, it can usually be expected that kidney function will return over several weeks Intrarenal ARF  ARF may also occur as a result of diseases that affect the nephrons themselves  Glomerular diseases (e.g. acute glomerulonephritis)  Medullary diseases (e.g. acute pyelonephritis)  Immune hypersensitivity disorders (e.g. Goodpasture’s syndrome)  Toxic chemicals (may include ATN as a cause) Postrenal ARF  Due to obstruction of the flow of urine from kidneys, at the level of the ureters, urinary bladder or urethra  Results in back pressure up the urinary tract to kidneys  Common causes  Nephrolithiasis  Benign prostatic hyperplasia  Urinary tract tumours ARF – Manifestations  Common manifestations  Oliguria/Anuria: a sudden drop/a complete cessation of urine production  Azotaemia: a raised level of nitrogenous waste compounds (e.g. urea) and creatinine in the blood  Uraemia (i.e. symptomatic azotaemia): azotaemia plus clinical signs such as lethargy, reduced appetite, vomiting, and depression  Other general signs and symptoms  HTN  Oedema  Hyperkalaemia  Malaise  Anorexia, weight loss  Pruritus Chronic renal failure  Also known as end-stage renal disease (ESRD) From long-term progressive and permanent loss of nephrons  More than 80% loss of nephron function  No possibility of nephron recovery  Requires regular dialysis or a kidney transplant  Develops in long-standing diseases affecting the kidney  Chronic glomerular disease  Chronic medullary disease (infections, cysts, etc.)  Also associated with  DM  Hypertension  Polycystic kidney disease Glomerulonephritis (GN)  Inflammation of glomeruli  Glomerular injury that are generally, but not always, due to inflammatory changes in the glomerular capillaries or glomerular basement membrane (GBM) or podocytes  Most types are immunologically mediated (e.g. AI)  kidneys are involved symmetrically  Accompanied by a secondary glomerular injury  Fibrin deposition, platelet aggregation, neutrophil infiltration and free radical-induced damage  Classified based on the histopathological appearances  Then a renal biopsy (Bx) is required GN Not Examinable Spectrum of glomerular diseases Nephritic Nephrotic vs Syndrome Syndrome 1. Haematuria 1. Massive proteinuria 2. Oliguria, oedema 2. Hypoalbuminaemia 3. Azotaemia 3. Oedema 4. Hypertension 4. Hyperlipidaemia IgA Nephropathy  One of the most common type of GN  Most common in 2nd and 3rd decade and Males  It is frequently preceded by an URTI or GI infection  Haematuria is a cardinal and the earliest sign (macroscopic)  HTN also presents, proteinuria is a late feature  Proteinuria denotes poor prognosis (towards ESRD)  No specific treatment is available  The management is therefore directed towards the control of blood pressure to prevent or decelerate progressive renal disease  Slowly progress towards end-stage renal failure in 25–40% of patients over a period of 30 years; occasionally rapidly!  Some evidence suggest benefits of high dose corticosteroids Post-streptococcal GN  PSGN is the most common type of post-infection GN  Frequently seen in children than adults  Follows a streptococcal infection (7-14 days latency)  Sore throat, Otitis media, Skin infection (cellulitis)  Clinical feature of nephritic syndrome + proteinuria  Management  Fluid and salt restriction, antihypertensives, diuretics, and dialysis if necessary  Corticosteroids may also be helpful.  The prognosis is often good in almost all children and many adults  A small number of adults develop hypertension and/or CKD later in life Urinary Tract Infection (UTI) UTI is used to describe acute urethritis, cystitis, prostatitis or pyelonephritis  Spectrum  Asymptomatic bacteriuria  Symptomatic acute urethritis and/or prostitis/cystitis  Acute pyelonephritis  Septicaemia (rare)  Organisms  E. coli and other coliforms (70%)  Proteus mirabilis  Klebsiella aerogenes  S. saprophyticus and epidermidis  STIs UTI  Clinical features  Usually slight or no systemic symptoms  Common in females  Dysuria  Frequency and urgency  Suprapubic pain during and after voiding  Cloudy urine that may have an unpleasant odour  Microscopic or visible haematuria  Back pain and Costovertebral angle tenderness  Pyelonephritis UTI – Risk factors Other Risk factors Hx of UTI Hx of unsafe sexual activity (STIs) Loss of host defences Atrophic urethritis and vaginitis in post-menopausal women Diabetes mellitus UTI – Investigation Clean-catch midstream specimen of urine  Presence or absence of pyuria  Presence or absence of nitrite  Dipstick tests positive for both nitrite and leucocyte esterase are highly predictive of acute infection (sensitivity of 75% and specificity of 82%)  Haematuria may also present  Urine culture and microscopy/cytology follow next Acute Pyelonephritis  Acute infections that ascend from the lower urinary tract or rarely spread haematogenously to the kidney(s)  Symptoms usually include  Fever, flank pain, nausea, vomiting, burning on urination, increased frequency, and urgency.  Tenderness over the kidney is a sign  Complicated pyelonephritis includes pregnant patients, patients with uncontrolled diabetes, kidney transplants, urinary anatomical abnormalities, acute or chronic kidney failure, as well as immunocompromised patients UTI – Treatment  The goal of treatment is to eradicate the bacteria thus Antimicrobial agents are the primary means of therapy  Recurrent infections need a more prolonged course of antibiotics plus rectifying any underlying causes  Fluid intake of at least 2 L/day is recommended  Asymptomatic bacteriuria must be treated in pregnancy Self-directed study topics  Oncotic (colloid-osmotic) pressure vs hydrostatic pressure  Nephrolithiasis  Causes, S & S, management, and prevention  Urinary incontinence  Types and their causes  SIADH  Causes, clinical features and management  Review BP regulation mechanisms and renin- angiotensin-aldosterone system  Reproductive System CHI335 Figures and tables from: Kumar & Clark’s Clinical Medicine Davidson’s Principles & Practice of Medicine Male reproductive system Spermatogenesis Female reproductive system Menstrual cycle and oogenesis Pertinent Investigations  Hormones level  Semen analysis  Prostate specific antigen (PSA)  Breast examination  Cervical screening test Semen analysis  Check the semen for  Volume  Sperm number (concentration)  Sperms’ motility  Sperms’ morphology Prostate Specific Antigen – PSA  A protein secreted by the epithelial cells of the prostate gland which could be traced in the blood  Used as a screening test for prostatic cancer  PSA 10 ng/mL  A prostatic biopsy will show cancer in over 50% of cases The National Cervical Screening Program  A five-yearly human papillomavirus (HPV) test for women aged 25 to 74 with a cervix who are sexually active or ever have been  Regardless of  Being gay, lesbian, bisexual, transgender or straight  Have had the HPV vaccination or not  Being no longer sexually active  Have been through menopause  Have been with only one sexual partner  Have experienced traditional cutting or circumcision  Have had a baby or being pregnant Reproductive system Common conditions STIs (STDs)  Chlamydial infection  Genital herpes  Gonorrhoea  Anogenital wart (HPV)  AIDS  Syphilis Chlamydial infection  Caused by Chlamydia trachomatis  The most common STDs in the world  Is usually asymptomatic in both men (50%) and women (80%)  Diagnostic factors  Asymptomatic (vaginal/penile swab, urine analysis, Antigen)  Dysuria (and conjunctivitis)  Penile/vaginal discharge  Lower abdominal/Pelvic pain  post-coital or intermenstrual bleeding Chlamydial infection  Management  Eradicate infection and follow up on sexual contacts  Delay in treatment increases risk of infertility  Antibiotic therapy  Treatment failures are uncommon  Reinfection is common  Complications  Salpingitis  Epididymo-orchitis  Reactive arthritis  Pelvic inflammatory disease (PID)  Ophthalmia neonatorum Genital Herpes  Herpes simplex virus: HSV-1 (oral) or HSV-2 (genital)  Transmission: vaginal, anal, oro-genital or oro-anal  Virus remains latent in the body  A very common type STI  Prevention  Avoid sexual contact  Use Condom Genital Herpes  Diagnostic factors  Fever, malaise, Headache  Tingling/itching  Painful genital/oral ulcers  Inguinal lymphadenopathy  Dysuria (in females)  Meningitis/encephalitis (aseptic)  Management  Topical antivirals – effective if used at very early stage  Antiviral therapy  Reduce contact when lesions are present Anogenital warts – HPV  Genotypes: HPV-6, HPV-11, HPV-16, HPV-18  The last two have strong associated with genital carcinomas  Skin to skin transmission  Lesion size ranges from a few millimetres to several centimetres  Exophytic and Single OR multiple and papular/flat  The number and size increase during the pregnancy  Lesions typically appear within weeks to months after exposure  Rarely can be transmitted to mouth during oral sex Anogenital warts – HPV  Prevention  Abstinence  Barrier methods such as condoms also may decrease the risk but are not entirely effective  Vaccines  Cervarix  Gardasil  Male circumcision may protect against HPV infection  Management  No cure  Resolve spontaneously  Removal of visible warts (laser, cryo, creams or lotions)  Complications  Cervical cancer (rarely oral and anal cancer) BPH  A benign enlargement of the prostate gland  Unknown aetiology  Hyperplasia of the glandular and connective tissues  Enlargement stretches, compress and distorts the urethra hence obstructing bladder outflow Risk factors Diagnostic factors Tests STRONG COMMON Age (> 50 yrs) Storage symptoms (frequency, urgency and nocturia) WEAK Voiding symptoms Urinalysis – normal OR pyuria (UTI) FHx (weak stream, hesitancy, PSA – normal or slightly elevated Non Asian race intermittency, incomplete emptying Smoking (retention), post void dribbling) Male pattern baldness UNCOMMON Metabolic Fever with dysuria syndrome BPH  Diagnosis  Age and Clinical presentation  Digital Rectal Exam  PSA  MRI / US  Management  Mild to moderate symptoms  Watchful waiting  Medications  Acute urinary retention  Urgent Catheterisation  Surgery  Transurethral resection of prostate (TURP)  Holmium laser enucleation  Open prostatectomy Endometriosis  Presence of endometrial tissue outside the uterine cavity Endometriosis  Tissue embedded on the serosal aspect of the organs  Common in age 20-45 and in nulliparous women  Cyclical engorgement and inflammation  Signs and symptoms  Asymptomatic (infertility)  Pain (Lower abdominal, Pelvic pain, Low back pain)  Heavy or irregular bleeding and dysmenorrhea  Dyspareunia  Dyschezia (pain on defecation) - Often with cycles of diarrhoea and constipation  Bloating, nausea, and vomiting  Pain on micturition and/or urinary frequency  Pain during exercise Pelvic Inflammatory Disease  PID is an infectious and inflammatory disorder of the upper female genital tract, including the uterus, fallopian tubes, and adjacent pelvic structures  PID is initiated by infection that ascends from the vagina and cervix into the upper genital tract. Chlamydia trachomatis is the predominant sexually transmitted organism associated with PID  The classic high-risk patient is a menstruating woman younger than 25 years who has multiple sex partners, does not use protection, and lives in an area with a high prevalence of STIs PID – Clinical presentation  May have very mild symptoms or  Toxic symptoms  Fever, nausea, vomiting  Severe pelvic pain  Lower abdominal pain  Abnormal vaginal discharge  Unanticipated vaginal bleeding, often postcoital  Complications  Chronic pelvic pain  Infertility  Ectopic pregnancy Self-study Topics  Gonorrhoea  Cause and S & S  Syphilis  Cause, stages and stage-specific S & S  Fibrocystic breast changes  PMS and PMDD  Signs and symptoms  PCOS  Clinical presentation and basics of management Or Scan the QR code below