Urinary pathology

• what is ectopic kidney

  when the kidney is positioned abnormally, usually at the pelvis (much inferiorly), and rarely at the thorax. usually will not cause symptoms unless there is urinary blockage or stones
• cause for ectopic kidney

  a congenital abnormality whereby the kidney will fail to ascend during foetal development
• RA for ectopic kidney

  -possibly may see the soft tissue outline of the kidney. however usually need contrast medium

  -often an incidental finding as usually asymptomic

  -US or CT often used
• treatment for ectopic kidney

  -if there's obstruction which prevents urine drainage, will need surgical correction

  -if there's renal damage, need nephrectomy (kidney removal)
• prognosis for ectopic kidney

  good but may develop further complications such as:

  -hypertension (HB pressure)

  -infection and calculus (stone) formation, usually with urine drainage problems

  -renal failure if reflux of urine back into kidney
• what is horseshoe kidney

  when the lower poles of kidneys fuse. more common in males and seen 1 in 400 adults
• symptoms of horseshoe kidney

  usually asymptomatic unless there is urinary flow impact from stones, and or infections
• causes for horseshoe kidney

  congenital disorder
• horseshoe kidney RA

  -not exactly evident so need contrast medium

  -previously use intravenous urogram

  -now use US or CT for clear isthmus (fusion seen on CT coronal)

  -incidental findings
• treatment for horseshoe kidney

  -if no renal symptoms, no treatment as separating kidneys can cause unnecessary risk to vascular supply with possible bowel injury as its close to the colon

  -if there are symptoms like blocked ureter from e.g kidney stones, use antibiotics or surgery to remove stones, or stenting to open ureters
• what is duplex system

  when kidney has two pelvi-calyceal systems (two renal pelvis and/or two ureters)
• cause for duplex system

  congenital where two ureteric buds develop, instead of one. ureters may fuse at any point of their length or separate at the bladder
• RA of duplex system

  -use contrast medium
• treatment for duplex system

  -no treatment usually required

  -though pt is usually prone to infections, reflux and, obstruction, so will need secondary treatments
• urinary calculi (stones)

  it is the presence of calculi in the urinary also known as urolithiasis. most common 30-60 yrs. can be asymptomatic but some have pain. the small stones in kidneys can pass through the ureter and cause obstruction and renal colic (severe pain). or possibly haematuria (blood in urine).
• urinary calculi stones

  the most common types of stones are calcium oxalte then calcium phosphate, then uric acid and struvite. size of these stones will vary from small gravel to large staghorns
• cause for urinary calculi

  unknown but maybe excess mineral salts that are produced and passes through the urinary tract
• RA for urinary calculi

  -depending on the composition of the stones. if calculi is passing through the ureter, it will be radio-opaque and won't need contrast

  -for expanded ureters use contrast medium for visualisation. urine may back up into the renal pelvis due (hydronephrosis) as the stone may obstruct the ureter

  -can use CT as will be seen as high attenuation for stones that are radiolucent

  -also use US and will be seen as hyperechoic. the density of the stones will reflect the sound waves shown as hyperechoic, a shadow will be casted behind it
• treatment of urinary calculi

  -will depend on the size, location and composition of stone

  -as most stones are 4mm, they will naturally pass through the ureter and into the bladder. so will need hydration, analgesia and antibiotics to prevent infection

  -for small calculi = shock wave lithotripsy

  -if kidney obstructed and/or severely infected = percutaneous nephrostomy for emergency to save the organ and prevent sepsis. (it is the insertion of tube through the skin and into the kidney. the catheter will relieve the urinary obstruction.)
• prognosis for urinary calculi

  good but if left untreated can affect function and structure of the kidney that is irreversible
• staghorn calculi

  large calculi composed of struvite that grows to form a cast of the renal pelvis and calices. this appears as horns of stag. mostly asymptomatic but pts may have pyrexia, haematuria, flank pain and potentially septicaemia and abscess formation
• staghorn calculi causes

  recurrent infection. more common in women and in those with renal tract and SC abnormalities
• RA staghorn calculi

  -mostly radio-opaque with branching calcific densities overlying the renal outlines

  -dont need contrast for CT
• treatment for staghorn calculi

  -surgical treatment to remove entire stone and small fragments as the residual fragments can cause infections and recurrent stone formation

  -if left untreated, it can result in chronic infection and severe organ damage, and sepsis
• describe hydronephrosis

  when the flow of urine is impeded, it flows back into the kidney. chronic hydronephrosis may produce permeant functional deterioration
• causes for hydronephrosis

  obstruction of urine flow by calculus or a tumour in bladder or in the abdomino-pelvic region that causes compression of the ureter
• RA for hydronephrosis

  -limited on xray so use with contrast medium to see the collection of urine in renal pelvis with dilation of ureter.

  -can use US and CT
• treatment for hydronephrosis

  -usually involves prompt treatment of infection with antibiotics and/or relief of any obstruction to prevent permeant loss of renal function

  -use ureteric stents to open up the ureter

  -percutaneous nephrostomy
• what is diverticular disease

  there is a protrusion of mucosa through the bladder muscle, usually multiple. these protrustions are not surrounded by muscle fibres so they are unable to empty during bladder contraction. usually asymptomatic but can lead to infection, stone or tumour formation. there may be formation of a hernia (palpable lump)
• cause of diverticular disease

  begin as small outpouches of the bladder at weakened areas of the muscle. usually caused from increased pressure as a result of bladder outlet obstruction. more common in men due to prostatic enlargement
• bladder diverticula

  -use contrast medium

  -can use CT or US or cystoscopy (surgical procedure with camera inside bladder)
• treatments for diverticula disease

  -resolve the bladder outflow obstruction with drug therapy or surgery

  -persistent infections is a sign for surgical removal of the diverticula
• describe bladder tumour

  -can be cancerous

  -an abnormal growth of tissue typically at the mucosa of the bladder. normally known as transitional cell carcinoma

  these tumours may eventually grow into the bladder detrusor muscles

  -common symptoms is haematuria
• causes for bladder tumours

  unknown but possibly smoking, exposure to chemicals, chronic irritation of the lining of the bladder
• RA for bladder tumours

  -use contrast medium

  -will see a 'filling' defect = when it doesn't fill with the contrast as expected, so will be seen as grey/darker regions

  -can use CT, US or cytoscopy
• treatment for bladder tumours

  -use cytoscopy to determine staging

  -biopsy for histological examination

  -full resection (removal) of tumor if it is superficial (no further than the detrusor muscle)

  -can use chemotheraopy to prevent recurrence and use cytoscopy to check recurrence

  -for more invasive tumours, use radiotherapy

  -cystectomy, the removal of the whole bladder, is the last resor. with this, use construction of a 'new bladder' using part of the bowel, or urostomy, a surgical procedure to create a stoma opening that drains urine in stoma bag