Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3998_Библиотеки_им_академика_М_И_Перельмана
.pdf
Stone disease 237
A5: What investigations would be most helpful and why?
Full blood count (FBC), renal function and electrolytes
Urine and blood cultures: most common organisms are coliforms (Escherichia coli, enterococci,
Proteus spp., Klebsiella spp.)
Ultrasonography: hydronephrosis, perinephric abscess
Radiograph of the kidney, ureter and bladder: underlying stone
CT urography: renal tract calcication and obstructing stones in the ureter
A6: What treatment options are appropriate?
Acute pyelonephritis is associated with fever and systemic symptoms for a shorter period and is treated
with antibiotics. Imaging often rules out the presence of infected hydronephrosis or pyonephrosis/
perinephric abscess. The antibiotics often work effectively within 4 to 5 days.
Impaired glomerular ltration inhibits the entry of antibiotics into the collecting system and requires
emergency decompression by means of either percutaneous nephrostomy or ureteral stenting. The best
course is treatment of sepsis and resuscitation as appropriate and urgent drainage of the kidney.
https://t.me/medicina_free
238 Urology
OSCE Counselling cases
OSCE COUNSELLING CASE 5.2 –
‘How do I prevent recurrent stone
formation?’
Increasing uid intake, of up to 2 L per day, to maintain clear urine
Animal protein restriction (reduced meat intake)
Moderate calcium intake. Dietary calcium restriction actually increases stone recurrence risk
by increase in the available intestinal oxalate. This increases intestinal oxalate absorption and
supersaturation of calcium oxalate. Calcium supplementation is safest when taken with meals and
calcium citrate is the safest and stone-friendly calcium supplement with the inhibitor action of citrate.
Reduced-sodium diet
Obese patients may produce acidic urine and have increased incidence of uric acid stone formation. A
low-carbohydrate, high-protein diet delivers a marked acid load to the kidney and increases risk of stone
formation.
OSCE COUNSELLING CASE 5.3 –
‘How do I counsel for extracorporeal
shock wave lithotripsy (ESWL)?’
Extracorporeal shock wave lithotripsy is a non-invasive form of stone fragmentation achieved by
directing shock waves onto the stone. Shock waves are generated by electrohydraulic, piezoelectric,
electromagnetic sources, which are focused onto the ureteric or renal calculus, resulting in stone
fragmentation. Stones are localized using radiographs or ultrasonography. A water-lled cushion in
a silicone membrane provides the interface between the patient and the shock wave generator to
minimize energy dissipation.
Acute UTIs, uncorrected bleeding disorders, pregnancy, sepsis and uncorrected obstruction distal to
the stone are all considered absolute contraindications. Patients with cardiac and pulmonary problems
are treated with caution. Dysrhythmias are common during lithotripsy and are controlled by cardiac
gating. In this setting, the shock wave is discharged by the R wave in the cardiac cycle, which prevents
most tachyrhythmias. Stone sizes >2 cm in diameter may require insertion of a JJ stent into the ureter to
aid passage of stone fragments, and prevent the distal obstruction of the ureter from impacted stone
fragments in the ureter – described as ‘steinstrasse’ (stone street).
The stone fragmentation rate depends on the stone composition, stone size and position; calculi
composed of calcium oxalate dihydrate, magnesium ammonium phosphate and uric acid fragment
readily with ESWL. Calcium oxalate monohydrate and certain forms of calcium phosphate stones
(e.g. brushite) are more difcult to fragment with ESWL and cystine stones are often resistant to such
fragmentation. Stones within the lower pole calyx with an acute infundibulopelvic angle often do not
clear, and this needs to be taken into consideration when offering advice.
The overall success rates are around 40 to 70 per cent.
The side effects of ESWL include pain, haematuria and loin bruising. Subcapsular haematomas in
the perinephric region may be associated with severe loin pain and bruising, and may require parenteral
opiates. Haematuria associated with stone fragmentation may present with clots. Pretreatment with
100 to 500 shocks at low energy levels to reduce lesion size and treatment at a slow rate of shock-wave
delivery (60 shocks/min or less) reduce the risk of renal trauma with shock-wave lithotripsy.
The cardiac dysrhythmias may occur with previous cardiac abnormalities.
https://t.me/medicina_free
Stone disease 239
REVISION PANEL
Ruptured abdominal aortic aneurysm is a differential diagnosis particularly in the older patient and
may be identied by palpating pulsatile aneurysm in abdomen or urgent imaging.
Loin pain may be associated with fever in pyelonephritis but also may be associated with
infection in a closed renal unit. The presence of hydronephrosis in the context of sepsis with renal
tenderness may require urgent drainage of the kidney with a nephrostomy or ureteric stenting.
CT without contrast is the accepted gold standard investigation for suspected ureteric colic.
Staghorn calculi may be asymptomatic or may have renal pain, recurrent urine infections or
microscopic haematuria.
Stones are often associated with infection and may require a multimodal approach to treat stones
often requiring more than one treatment.
Renal tract anatomy may be important to rule out coexisting abnormal anatomy.
Obstructed kidney with sepsis leads to accelerated nephron loss. Infection in an obstructed kidney
may lead to infected hydronephrosis or pyonephrosis. Treatment is drainage of the pus.
Two factors differentiate pyonephrosis and acute pyelonephritis. Pyonephrosis is often associated
with a prolonged period of fever prior to clinical presentation and often does not respond well to
antibiotics alone and may require drainage.
https://t.me/medicina_free
240 Urology
BLADDER OUTFLOW OBSTRUCTION
Questions
Clinical cases
For each of the clinical case scenarios given
Q1: What is the likely differential diagnosis?
Q2: What issues in the given history support/refute a particular diagnosis?
Q3: What additional features would you seek to support a particular diagnosis?
Q4: What clinical examination would you perform and why?
Q5: What investigations would be most helpful and why?
Q6: What treatment options are appropriate?
CASE 5.7 –
‘My urine ow is poor’
A 64-year-old painter presents with a reduced urinary stream and incomplete emptying of the bladder
with nocturia of two to three times a night. He is a smoker and has ischaemic heart disease.
CASE 5.8 –
‘I am unable to pass urine’
72-year-old man presented with painful inability to pass urine after having much to drink at his
daughter’s wedding.
CASE 5.9 –
‘My husband is confused and wet’
A lady presented with her 74-year-old husband who was increasingly confused and smelling of urine
and wetting the bed.
https://t.me/medicina_free
Bladder outflow obstruction 241
OSCE Counselling case
OSCE COUNSELLING CASE 5.4 –
What are the effects of surgery on the
prostate?
https://t.me/medicina_free
242 Urology
Key concepts
LOWER URINARY TRACT SYMPTOMS:
Bladder outow obstruction
Benign prostatic enlargement
BPH
Acute urinary retention
Acute or chronic urinary retention
Chronic urinary retention
Detrusor failure.
https://t.me/medicina_free
Bladder outflow obstruction 243
Answers
Clinical cases
CASE 5.7 –
‘My urine ow is poor’
A1: What is the likely differential diagnosis?
BPH
Urethral stricture
Prostatitis
Prostate cancer
A2: What issues in the given history support/refute a particular diagnosis?
Lower urinary tract symptoms (LUTS) may be voiding in nature, when they present with hesitancy,
reduced stream or interrupted stream. Voiding LUTS are often associated with bladder outow
obstruction but may also be due to detrusor failure. The diagnosis of BPH is histological in the prostate
and is primarily obstructive but it also produces changes in bladder compliance that result in increased
storage symptoms. Storage LUTS present with frequency of micturition, nocturia and urgency with or
without urgency incontinence. The post-micturition LUTS are sensation of incomplete emptying and
post-micturition dribble.
A3: What additional features would you seek to support a particular
diagnosis?
Aetiology: previous endoscopic procedures or infections, stone disease, family history of prostate
cancer
General tness and quality of life: co-morbidity with ischaemic heart disease, hypertension, diabetes
Scoring systems exist that would quantify the lower urinary tract dysfunction and the effect on the
quality of life (i.e. international prostate symptom score [IPSS]). It also includes bothersomeness. This
is important to determine treatment.
A4: What clinical examination would you perform and why?
Examination of the abdomen for a palpable bladder or masses and DRE to assess the size and
consistency of the prostate are performed. Prostate tenderness is often associated with prostatitis.
A5: What investigations would be most helpful and why?
A frequency volume chart would be helpful as would urine dipstick, midstream urine (MSU) for culture
and sensitivity, blood for serum creatinine, serum prostate-specic antigen (PSA) (if aged between
45 and 70 years and/or clinical examination suggests malignancy), urine ow rate and post-void
residual volume of bladder by ultrasonography. Suspicious DRE or abnormal PSA must be appropriately
investigated to rule out prostate cancer. Bladder or pelvic pain and neurological disease may need
specialized investigations. Haematuria with lower urinary tract symptoms should be investigated as for
haematuria.
A6: What treatment options are appropriate?
Conservative treatment: advice to all patients should be appropriate uid intake; avoid caffeine or
bladder stimulants and reduce intake of uid after 8.00 p.m. Advise regarding bladder training.
https://t.me/medicina_free
244 Urology
Management depends on severity of symptoms (scored using an International Prostate Symptom
Score [IPSS]) and bothersome LUTS. Voiding LUTS in patients with conrmed poor ow with a small-
sized prostate may be treated with lifestyle and uid advice, bladder retraining and alpha blockers.
A larger prostate in the same group of patients may get added benet from ve alpha reductase
inhibitors. PDE-5 inhibitors are shown to have similar efcacy in patients with voiding LUTS; there may
be a role of treating patients with both erectile dysfunction (ED) and bladder outow obstruction with
PDE-5 inhibitors daily.
CASE 5.8 –
‘I am unable to pass urine’
A1: What is the likely differential diagnosis?
Obstruction to the urine outow: prostatic enlargement
Stress
Neurological conditions: common in patients with multiple sclerosis and spinal cord compression
(cauda equina lesion); consider this diagnosis in patients with associated abnormal neurology and in
younger patients
A2: What issues in the given history support/refute a particular diagnosis?
History of previous obstructive lower urinary tract symptoms
A3: What additional features would you seek to support a particular
diagnosis?
Triggers for acute urinary retention may be the following:
Urine infection
Alcohol intake
Exacerbation of chronic obstructive airway and use of inhaled β-receptor agonists, or any drug with
anticholinergic effects or α-adrenergic effects, such as antihistamines and ephedrine sulfate, which
may precipitate retention
Post-operative (major pelvic or orthopaedic surgery)
Constipation
Other conditions including genital herpes, urethral stone, prostatitis and haematuria with clot retention
Medical history of co-morbidity: diabetes, renal impairment.
Assess suitability for surgery and for α blockers (would cause postural hypotension, and judicious use
is needed in elderly patients with compromised cardiovascular systems).
A4: What clinical examination would you perform and why?
Conrm palpable bladder and abdominal examination to identify masses.
Use DRE to identify masses in rectum and prostate assessment.
Perform focused neurological examination including power and tendon reexes in the legs
and feet, examination for loss of sensation in the legs, feet and perineum. Test for anal tone,
contraction of pelvic oor muscles and the presence of the bulbocavernosus reex (tests the
integrity of the sacral cord reex, i.e. pudendal afferents, sacral segments S2–4 and pudendal
efferents). This is seen as a reex contraction of the pelvic oor on stimulation of the glans or
clitoris. This may also be elicited by gently pulling the urethral catheter.
A5: What investigations would be most helpful and why?
Catheter specimen of urine for microscopy and culture: UTI
Serum creatinine: renal dysfunction caused by back pressure into the renal collecting system
Ultrasonography of renal tract: assessment of kidneys
https://t.me/medicina_free
Bladder outflow obstruction 245
A6: What treatment options are appropriate?
Initial treatment: symptomatic pain control, relief of retention with a urinary catheter may be
provided.
Medical treatment: there is a role for α blockers in acute urinary retention. This can be started and a
trial without catheter may be given within 48 hours of starting the treatment. If this fails the options
are either to proceed to surgery or to give another trial without a catheter in 2 weeks.
Surgical treatment: the ‘gold standard’ procedure is a transurethral resection of the prostate (TURP).
However, there are several other modalities of treatment including laser coagulation and enucleation
that are being developed to achieve the same effect.
CASE 5.9 –
‘My husband is confused and wet’
A1: What is the likely differential diagnosis?
Acute confusional state with incontinence:
Diabetic acidosis, electrolyte abnormalities
Infections and dehydration
Cerebral metastasis
Intracranial haemorrhage/cerebrovascular accident (CVA)
A2: What issues in the given history support/refute a particular diagnosis?
Gradually increasing confusion and urinary incontinence may be caused by urinary retention, with
backpressure on the renal collecting system causing uraemia. Urinary tract infections or sepsis
may lead to general deterioration of health and confusion with loss of control of bodily functions.
Cerebrovascular accident or intracranial haemorrhage is associated with a neurological decit.
A3: What additional features would you seek to support a particular
diagnosis?
Chronic retention is a non-painful bladder that remains palpable or percussable after the patient has
passed urine. Such patients may be incontinent. Chronic retention may occur in patients with detrusor
underactivity, detrusor hyperactivity with impaired contractility or neurogenic bladder conditions and
bladder outow obstruction. Chronic urinary retention is generally classied as high-pressure and low-
pressure chronic retention. The low-pressure group complained of hesitancy, slow stream and a feeling
of incomplete emptying. The high-pressure group complained of urgency, and there is an association
with upper tract dilatation and obstructive uropathy and raised creatinine.
A4: What clinical examination would you perform and why?
Clinical examination should be performed to identify palpable bladder, DRE for constipation, rectal
lesions and assessment of prostate; also a focused neurological examination should be performed.
Chronic retention may be associated with neurological disease and clinical examination may identify
spinal cord compression or cauda equina lesion.
A5: What investigations would be most helpful and why?
Urine dipstick and microscopy: to rule out infection
U&Es: uraemia
Ultrasonography to identify hydronephrosis and renal cortical thickness (long-standing
hydronephrosis is associated with a thinning of the renal cortex)
https://t.me/medicina_free
246 Urology
A6: What treatment options are appropriate?
Catheterization in chronic retention has the risk of inducing sepsis, and decompression of urine and
pressure in the renal collecting system are associated with haematuria and a post-obstructive diuresis.
The haematuria may need to be treated with bladder washouts. It is important to correct the volume
depleted as a result of diuresis to prevent a dehydration-induced/hypovolaemic acute tubular necrosis, in
addition to the existing renal dysfunction.
https://t.me/medicina_free
Соседние файлы в папке Библиотека им академика М.И. Перельмана